Cardiac Catheterization in Congenital Heart Disease: Pediatric and Adult - Part 1 pps

2 Medications used in or in conjunction with the cardiaccatheterization laboratory and patient preparation for cardiac catheterization, 25 3 Cardiac catheterization equipment, 74 4 Vascu

Catheterization

in Congenital

Heart Disease: Pediatric and

Adult

Charles E Mullins, MD

Professor of Pediatrics

Baylor College of Medicine

Texas Children’s Hospital

Houston, Texas

USA

Catheterization

in Congenital

Heart Disease: Pediatric and

Adult

Charles E Mullins, MD

Professor of Pediatrics

Baylor College of Medicine

Texas Children’s Hospital

Houston, Texas

USA

Blackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts 02148-5020, USA

Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK

Blackwell Science Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia

All rights reserved No part of this publication may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without permission in writing from the publisher, except by a reviewer who may quote brief passages in a review.

Cardiac catheterization in congenital heart disease : pediatric and

adult / Charles E Mullins.

p ; cm.

Includes bibliographical references and index.

ISBN–13: 978–1–4051–2200–9 (hardback : alk paper)

ISBN–10: 1–4051–2200–5 (hardback : alk paper)

1 Cardiac catheterization in children 2 Congenital heart disease

in children—Surgery 3 Cardiac catheterization I Title.

[DNLM: 1 Heart Defects, Congenital—diagnosis 2 Heart Defects,

Congenital—therapy 3 Heart Catheterization—methods WG 220

M959c 2005]

RJ423.5.C36M85 2005

618.92′120754—dc22

2005022329

A catalogue record for this title is available from the British Library

Acquisitions: Steve Korn

Development: Simone Dudziak

Set in 9.5/12 Palatino by Graphicraft Limited, Hong Kong

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Notice: The indications and dosages of all drugs in this book have been recommended in the medical

literature and conform to the practices of the general community The medications described do not necessarily have specific approval by the Food and Drug Administration for use in the diseases and dosages for which they are recommended The package insert for each drug should be consulted for use and dosage as approved by the FDA Because standards for usage change, it is advisable to keep abreast of revised recommendations, particularly those concerning new drugs.

2 Medications used in or in conjunction with the cardiac

catheterization laboratory and patient preparation for

cardiac catheterization, 25

3 Cardiac catheterization equipment, 74

4 Vascular access: needle, wire, sheath/dilator and

8 Transseptal left heart catheterization, 223

9 Retrograde arterial cardiac catheterization, 255

10 Hemodynamics, data acquisition, and interpretation

and presentation of data, 272

11 Angiographic techniques, 325

12 Foreign body removal, 350

13 Balloon atrial septostomy, 378

14 Blade/balloon atrial septostomy, special atrial

septostomies, atrial “stent septostomy”, 392

15 Balloon dilation proceduresageneral, 410

16 Pulmonary valve balloon dilation, 430

17 Dilation of branch pulmonary artery stenosis, 441

18 Dilation of coarctation of the aortaanative and

22 Intravascular stents in congenital heart

diseaseageneral considerations, equipment, 537

23 Intravascular stent implantapulmonary branch

stenosis, 597

24 Intravascular stents in venous stenosis, 623

25 Coarctation of the aorta and miscellaneous arterialstents, 642

26 Occlusion of abnormal small vessels, persistentshunts, vascular fistulae including perivalvular leaks, 661

27 Transcatheter occlusion of the patent ductusarteriosus (PDA), 693

28 Transcatheter atrial septal defect (ASD) occlusion, 728

29 Occlusion of the patent foramen ovale (PFO), atrialbaffle fenestrations and miscellaneous intracavitarycommunications, 780

30 Transcatheter closure of ventricular septal defects, 803

31 Purposeful perforation of atretic valves, otherintravascular structures and recanalization of totallyobstructed vessels, 842

32 Special innovative or new, therapeutic catheterization

procedures and devices, 859

33 Endomyocardial biopsy, 869

34 Phlebotomy, pericardial and pleural drainage, 881

35 Complications of diagnostic and therapeutic cardiaccatheterizations, 895

Index, 925

In addition to the essential diagnostic information that

still only can be acquired from a precise and detailed

car-diac catheterization, definitive therapy in the catheterization

laboratory has become the major indication for cardiac

catheterization for many of the lesions in pediatric and

congenital heart patients The numerous therapeutic

pro-cedures performed in the cardiac catheterization

labor-atory have generated an even more essential and often,

more challenging, need for extremely precise and

pur-poseful maneuvers with cardiac catheters The catheters

for the delivery of balloons and/or devices must be

posi-tioned in very precise locations, not just into the general

vicinity of the lesion

In order to proceed with the appropriate and expedient

therapeutic catheter intervention, the accurate diagnosis

must be acquired, a decision must be made on the basis of

that information during the procedure and then,

immedi-ately, the information is acted upon therapeutically In

most cases, the therapeutic procedure is performed

dur-ing the same catheterization procedure without a decision

by “conference” The therapeutic catheterization

proced-ures have resulted in the development of new equipment

along with entirely new procedures and techniques, which

catheterizing physicians not only must become familiar

with, but also must be experts in performing

The therapeutic catheterization procedures also have

stimulated a new collaboration between the tional cardiologist and the congenital heart surgeon Inprogressive institutions, the catheterizing interventionalcardiologist plans his diagnostic and therapeutic catheter-ization interventions based on the stage of surgical repair,which is to be performed subsequently in the operatingroom The surgeon also can plan his procedure based onthe knowledge that a subsequent therapeutic intervention

interven-to “complete the repair” may be performed more ently in the catheterization laboratory More and more fre-quently, therapeutic catheter interventions are performed

expedi-in conjunction with the surgeon expedi-in the operatexpedi-ing room.

Therapeutic catheterizations that are performed in theoperating room overcome some access problems for thecatheter intervention and at the same time allow better

myocardial protection with shorter, or even no

cardiopul-monary bypass and/or arrest times during the operativeprocedure

This text is intended to provide detailed instructions formost of the therapeutic catheterization procedures pres-ently in use for congenital heart defects Although many

of these specific catheter maneuvers are useful duringintracardiac electrophysiologic procedures, the specificelectrophysiologic diagnostic and therapeutic interven-tions represent an entirely separate specialty and are notdiscussed in this text

The cardiac catheterization room itself

A current cardiac catheterization laboratory ideally

should be at least 32 feet long by 24 feet wide In addition

to the large length and width requirements of the

catheter-ization room, the ceiling height must be at least 14 feet in

order to accommodate the suspension system of the X-ray

tubes and intensifiers from any manufacturer The only

“fixed” equipment in the actual catheterization room

should be the catheterization table and the suspension

systems for the X-ray systems along with the X-ray and

physiologic monitors, with no fixed cabinets and none of

the X-ray generating equipment included within the

actual catheterization room The arrangement of the

catheterization table in the room and the “connections” or

“communications” to the room from adjacent areas

depend upon the “real estate” which is available

immedi-ately adjacent to the catheterization room The control

room for the physiologic and X-ray systems must be

adjacent to the catheterization room and have at least

a doorway access to the laboratory The control room can

be positioned at the end or at the side of the

catheteriza-tion room, but in either locacatheteriza-tion the operators in the

control room should have a clear view of the patient on

the catheterization table The storage for the majority of

the expendable catheterization equipment should be

immediately adjacent to the catheterization room with a

readily accessible doorway The catheterization room

should have a one-and-a-half or even a double-width

doorway for patient access Even though the patient may

arrive on a narrow hospital stretcher, there must be the

capability of leaving the room easily with “attached”

equipment and personnel adjacent to or alongside of the

bed/stretcher during a resuscitation or emergency

trans-fer to an operating room

The scrub sink(s) for the catheterization laboratories

should be located outside of the actual catheterization

room in an adjacent “clean” corridor or room It is

essen-tial that all personnel in the laboratory scrub before

work-ing in the room and that the physicians scrub between

each case At the same time, scrubbing, which is a

rela-tively short task, is performed before the catheterization

procedure It has nothing to do with the procedure itself, it

actually can have “dirty” fluids splashing away from the

sink and, as a consequence, there is no justification, nor

logic for having the scrub sink occupy valuable space

within the catheterization room

During the course of an interventional catheterization

pro-cedure the catheterization room can become very crowded

with equipment and personnel The location and

arrange-ment of each piece of fixed equiparrange-ment become critical for the

most efficient and safe completion of the procedure

X-ray equipment

The basic equipment in a catheterization laboratory for pediatric and congenital heart patients includes a biplane X-ray system with compound angulation capabil-ities, an extra-long catheterization table and dual (quad-ruple!) CRT or flat panel monitor screens This basicequipment requires a very large “footprint” of floor space

in the room for just the catheterization table and the suspension systems for the X-ray tubes/intensifiers Thecatheterization table needs to be “extra long” or have along extension at the foot end in order to prevent the con-tamination of the very long catheters, delivery systemsand exchange length wires which are introduced andundergo multiple exchanges through the femoral vessels.The footprint of the catheterization table and the suspen-sion system for the X-ray tubes/intensifiers shouldinclude enough width to allow unimpeded rotation of the X-ray tubes and support arms without bumping into

or having to move other equipment There must besignificant space towards the head of the table to allowclear cephalad–caudal movement of the suspension system, space for physicians working from the head-end

of the table, adequate space for relatively large

anesthe-sia/respiratory equipment adjacent to the head and room

to have a transesophageal echo console adjacent to thepatient’s head It is often necessary to have all of this spaceoccupied at the same time! Additional floor space cepha-lad to, and away from the working areas is required to

“park” the lateral X-ray suspension gantry a distanceaway from the head of the catheterization table in order

to allow room for transferring the patient to and from the table

The catheterization table

The spacial orientation of the catheterization table withinthe room helps to optimize the usable space When thecatheterization table is placed at an angle, somewhat diag-onally across the room, this opens up a large area on oneside of the table at the head of the table and an equallylarge area on the opposite side at the foot of the table.When the larger space at the head of the table is on the side

of the access doorway for the patient, this allows a moreconvenient access to the table for a patient on a stretcher

As an added bonus, the extra space in this area opens up

an area for a transesophageal echo machine working fromthe head of the table The larger open area at the foot and

on the opposite side of the table allows more workingspace for the physicians on that side of the table A straightalignment of the table along the long axis in a slightly nar-row room compromises the space on both sides of thetable and for its entire length

Work space for the physician/operators

In addition to the large space requirement for the X-ray

equipment and the catheterization table, there must be

liberal space adjacent to, and all around, the

catheteriza-tion table/X-ray equipment to allow access to the table for

other large pieces of support equipment This space

should allow unrestricted movement of the X-ray tubes

and intensifiers as well as the free movement of the

per-sonnel within the laboratory around all of this equipment

regardless of the positions of the X-ray tubes The monitor

screens are grouped together as a bank of monitors on a

large ceiling mounted support, which is on tracks and is

movable about the table The operating physician must

have a clear view of all of the monitors while looking

for-ward (not over his shoulder or behind him), regardless

of the site of catheter introduction into the patient A very

satisfactory arrangement is to have the bank of monitors

mounted on a long swivel arm which, in turn, is on ceiling

tracks aligned across the catheterization table at the foot of

the table With this configuration, the monitors can be

moved directly over the foot of the table when vascular

access is from either side of the neck or even the arm, and

completely across the table when vascular access is totally

from the left side of the patient A long support arm on a

swivel base for the bank of monitors allows sufficient

movement of the monitors along either side of the table

With the multiple locations which are possible for the

monitors, the operator can always be located across the

table and facing the monitors with an unobstructed view

of them without any body contortions or having to look

round structures or behind him/herself

The exact configuration of the catheterization table

varies from laboratory to laboratory Most catheterization

tables are orientated for a right handed operatorai.e with

any extra space for the scrubbed physician(s)

predomin-ately on the right side of the patient’s trunk The person

who operates the controls for the movement of the table

and X-ray tubes and the person who operates the

pres-sure/flush manifolds and the flush lines, all vary from

laboratory to laboratory and affect how the

catheteriza-tion table is configured There must be adequate space for

two, or possibly three, scrubbed operators on either side

of the catheterization table particularly during complex

therapeutic interventional procedures, when as many as

four individuals may be scrubbed with several personnel

on both sides of the table when the vascular access is

from both sides It also should be possible for at least two

operators to work together from either side of the head

and neck area while other operators are working from the

femoral areas

In the catheterization laboratories at Texas Children’s

Hospital, the table position/movements, the movement

of the C-arms suspending the X-ray tubes, the collimation

of the X-ray tubes and the control and replay functions ofthe angiograms all are controlled by the catheterizingphysician(s) As a consequence these controls are all main-tained sterile with sterile covers/drapes and are posi-tioned on the same (right) side of the patient as theoperator, but nearer the foot of the table In some laborator-ies these table/cine controls are operated by a separatetechnician or even a radiologist, in which case the controlsare at the foot of the table or even physically away fromthe table on a separate stand

In addition to the space for the table controls, an additional length of the table “real estate” along one side

or the end of the catheterization table is required for thepressure transducers, pressure/flush manifolds and theflush/pressure lines The manifold is a series of three ormore, three-way stopcocks to which each transducer andthe tubing to both the fluid reservoirs and to the patientare connected In addition, the transducers are attached toelectrical cables which run from the transducers to an elec-trical connection on the table and eventually to the physio-logic recorders When three or four transducers are usedsimultaneously during a case, the manifolds holding the transducers occupy a meter, or more along one edge

of the table Three-way stopcocks on the manifold allow

“opening” the transducer to environmental pressure for balancing, as well as additional connections for the flush tubing to the transducers and separate tubing forflush/pressure lines to the patient from each transducer

In some catheterization laboratories where multichannelpressure recording is not used routinely, the manifold andeven the transducers themselves are positioned on thecatheterization “field” and operated by the catheterizingphysician Specifically arranged manifolds including thestopcocks, transducers and tubing are available commer-cially (Merit Medical Systems, Salt Lake City, UT) Theexact positioning of the manifold on the surface or alongthe side of the table will depend upon which personneloperate the manifold during the case

During the catheterization procedure, the manifoldwith the transducers ideally is fixed to the catheterizationtabletop at a specific height on a stand which allows an ini-tial adjustment in the height of the manifold to compen-sate for the “height” of the heart within the patient’s chestabove the tabletop The exact level (height) for the pres-sure transducers varies and is determined for each indi-vidual patient according to the anterior–posterior (AP)diameter of the chest The height for the transducer is themeasured distance from the tabletop to the mid level ofthe posterior–anterior chest diameter, or the exact location

of the heart is determined on the lateral fluoroscope Theheight from the tabletop to the heart should be measuredaccurately with a ruler and then this exact measurement is

transferred to the transducer stand to determine the

height of the transducers on the stand When the

trans-ducers are attached to the table at the correct level on a

stand, the transducers then move up and down with the

patient when the table is raised or lowered and, in doing

so, the reference height to the heart for accurate pressure

measurements always remains exactly the same

In the catheterization laboratories at Texas Children’s

Hospital, there are usually four transducers with as many

as six to eight color-coded flush/pressure lines passing to

the patient from pressure/flush manifolds Each

color-coded pressure line corresponds to a similar colored

pres-sure curve which is displayed on the monitors The entire

manifold is operated by a designated nurse/technician

who has no other assigned duty during the procedure In

this circumstance, the optimal position for the transducers

is on the opposite side of the catheterization table as far

as possible toward the foot of the table away from the

operating physicians, but still within the sight of the

catheterizing physician Since the majority of catheter

manipulations by the catheterizing physicians are

per-formed through the femoral vessels and from the right

side of the patient, regardless of whether the catheter is

introduced from the right or left femoral vessels, the

trans-ducers optimally are fixed, semi-permanently, on the left

(opposite) side of the table and as far as possible toward

the foot of the table

In some laboratories where one, or at most two

trans-ducers are used, the catheterizing physician operates the

manifolds including the transducers, the stopcocks, and

all of the fluid/pressure lines In this circumstance, the

manifold is fixed on the catheterizing physician’s side of

the table or actually laid on the patient’s legs on the

catheterization field This arrangement is more suited

when the catheterization laboratories are used

predomin-ately for adult (coronary) catheterizations where less

sophisticated hemodynamics usually are necessary

Regardless of which vascular access site is used, there

must be space located immediately behind the

catheteriz-ing cardiologist for at least one 30″ × 60″ work table to

hold flush solutions, a container of contrast solution,

needles, catheters, wires, instruments and other

expend-able equipment The work texpend-able should have enough room

around it to allow the “circulating” personnel and the

operators to have access to and around the table without

bumping into, or contaminating, it Two large (30″ × 60″)

work tables placed end to end behind the operators are

optimal for interventional procedures where multiple

long balloon catheters or very long delivery systems

for device implants are utilized The additional length of

the two tables positioned end to end allows sufficient

workspace for the preparation of the long balloon dilation

catheters and device delivery catheters The very long

table prevents these long items from hanging over the

ends of the table and from being contaminated when theyare stretched out lengthwise during their preparation orloading procedures

Anesthesia space requirements

The anesthesiologist, along with the space for the sia machine, requires access to the patient’s head fromeither the right or left side of the patient The anesthesia

anesthe-access is cephalad to the lateral X-ray support (“C”) arm

and must allow a convenient connection of the anesthesiamachine/tubing to the patient’s airway Connections foroxygen, gas and suction lines usually come through the anesthesia machine from a separate ceiling- or wall-mounted console near the head of the catheterizationtable It is essential that the oxygen, gas, suction consolealso is somewhat mobile and can be moved close to thepatient’s head for situations where general anesthesia and

an anesthesia machine are not being used

When general anesthesia is being used, the ogist controls the patient’s airway while simultaneouslyoperating the anesthesia machine This requires a closeproximity of the anesthesia machine to the head of thecatheterization table Anesthesiologists usually prefer theright side of the patient’s head; however, when vascularaccess for the catheterization is available only from theright neck, it is preferable that the endotracheal tube con-nections to the anesthesia machine approach from thepatient’s left side In rare circumstances, where vascularaccess and a complex procedure are to be from the rightside of the patient’s neck, it is desirable to have the anes-thesia machine on the patient’s left, as well

anesthesiol-A mobile, floor anesthesia machine provides more ibility than a ceiling-mounted anesthesia machine whenchanges in the orientation of the room may be necessary toadjust for different access sites to the patient At the sametime, the floor anesthesia console does occupy consider-able floor space

flex-This same need for sufficient room for access from aparticular side of the head holds true for the patient who is

on ventilator support without general anesthesia wherethe ventilator and the connecting tubing need a specificarea and room for access With or without a ventilator, asuction line/apparatus must always be adjacent to thepatient’s mouth and airway and must be immediatelyaccessible

Transesophageal echo

Although the transesophageal echo (TEE) console maynot be “parked” permanently in the catheterization labor-atory, the increasing frequency of use of TEE during con-genital cardiac catheterizations has created an additionalsemi-permanent space requirement very close to the head

of the catheterization table The connecting cable between

the TEE probe and the echo console is relatively short, and

the person manipulating the TEE probe frequently

oper-ates the console while manipulating the probe As a

con-sequence, the large TEE console is positioned very close to

the head of the table It must be possible to have access to

the patient with the TEE probe and the TEE machine from

either right or left side of the head of the table The location

of the TEE depends upon whether vascular access for the

catheterization is from either the arm or neck and, in

addi-tion, on which side of the head the anesthesia access is

located The current TEE consoles also have a large

foot-print and necessitate a large amount of space cephalad to

the head of the catheterization table, regardless of which

vascular access to the patient is used

The TEE machine is usually operated with the echo

con-sole positioned cephalad to the support arm for the lateral

X-ray tube and intensifier and to the left of the patient’s

head This places the echo console with its monitor and

the operator cephalad to (and behind) the lateral image

intensifier and out of the view of the catheterizing

physi-cians An additional mobile “slave” monitor away from

the TEE machine will then be necessary in order for the

operating cardiologist to see the TEE image The remote

monitor can be positioned away from the TEE console and

directly in front of the catheterizing physicians, in order to

allow the TEE image to be visualized continuously, no

matter where the catheterizing physicians are positioned

around the table relative to the TEE console Ideally the

slave TEE monitor is mounted with the other ceiling

sus-pended (X-ray and physiologic) monitors Another

alter-native is to have the slave monitor of the TEE mounted on

a mobile floor cart, which can easily be moved to any

open, viewable position around the table Some X-ray

systems allow a “picture in picture” positioning of the

TEE image within the image of one of the X-ray monitors

This is not as satisfactory as may be perceived If it is large

enough to be usable the superimposed TEE image

oc-cupies approximately one-fourth of the X-ray image and

always extends into, and compromises, the critical, central

area of the X-ray image.

Whenever either X-ray tube is in an LAO-cranial

posi-tion, the TEE console and the TEE operator physically

compete with the location of the image intensifier This

requires good communication and, usually, some

dis-placement of the TEE operator and the console when

the X-ray tube/intensifier are rotated into, and remain in

that position

Adjunctive equipment required within the

catheterization room

There is a considerable amount of additional, essential,

but at the same time, usually mobile equipment in the

modern catheterization laboratory This equipment, though mobile, remains in the catheterization room andtakes up a finite, and often a significant amount of addi-tional floor space there This equipment includes theemergency medication/defibrillator cart, often a separatemedication cart, the apparatus for blood oxygen satura-tion determinations, a patient-warming system, a cardiacoutput computer, and space for the mobile storage of veryfrequently used, consumable supplies In some laborator-ies the angiographic injector, radiographic protectiveequipment, suction equipment and adjustable “operatingfield” lights are on floor-mounted, mobile stands, inwhich case they require additional floor space

al-Emergency cart/defibrillator

Each cardiac catheterization room must have a mobile diac defibrillator and an “emergency cart” containingmedications and resuscitative equipment The defibrilla-tor should have a rechargeable battery source of power inaddition to a fixed source of (wall) electrical power Oftenthe emergency cart and defibrillator are combined intoone mobile cart The emergency cart contains items toestablish an oral or nasal airway, equipment for endotra-cheal intubation, equipment to start intravenous or intra-arterial lines, suction catheters and the accessories for thedefibrillator Whenever a patient is in the room, the items

car-on the emergency cart and the defibrillator must be able immediately and conveniently to the personnel in theroom and to the patient This, however, does not require

avail-that the emergency cart and defibrillator always be ately adjacent the patient However, the supplies on the

immedi-emergency cart are organized in such a way that the tion of each item on the cart is known instinctively and

loca-each item is available immediately to all personnel in the

room The defibrillator is turned on with the appropriatepaddles for the patient attached to it and the paste for thepaddles readily available The correct voltage according

to the size of the patient is set and the defibrillator isplaced in a location from which there is immediate andunobstructed access to the patient during the procedure

Medication tray/cabinet

In addition to the emergency and defibrillator cart(s), eachcatheterization room has a separate, readily accessible,medication tray or cart The medication cart contains all ofthe emergency drugs, sedatives, and other medicationsused both in emergencies and more routinely in the cardiac catheterization laboratory as well as a variety ofintravenous fluids The details of the medications whichare maintained in the medication cart are discussed

in Chapter 2 This medication tray is located in close proximity to the manifold containing the transducers

and flush lines When a nurse is operating the manifold,

this nurse has immediate access to the medication cart

and usually is responsible for administering medications

from the cart

Operating lights for the catheterization table

Movable or widely adjustable, focused lights over the

operating field are essential in the catheterization

laborat-ory Free-standing floor lights, mounted on a mobile stand

and with a long neck that extends over the catheterization

table, were the standard for years and are still used in

some institutions These floor lights take up additional

floor space immediately adjacent to the catheterization

table, they often do not permit the light source to shine

from the correct direction on the specific field, creating

shadows rather than light over the working areas, and

they are a constant potential for contamination of the

ster-ile field Ceiling-mounted operating room lights on long

movable arms are the standard in most catheterization

laboratories at the present time Ceiling-mounted lights

conserve floor space and allow the light to be directed

more appropriately, but, when there are other

ceiling-mounted accessories (angiographic contrast injectors and

radiation protection screens), the ceiling-mounted lights

add to the congestion in the area immediately above the

catheterization table due to the multiple suspension arms

This congestion of the arms creates a problem in the

optimal use of the other accessories

The ideal lights for the catheterization laboratory are a

set or group of recessed, high-intensity, focused, ceiling

lights, which can be directed toward a specific spot on the

catheterization table with a remote apparatus The lights

are adjusted by a small hand-held strobe light or “light

wand”, which is positioned immediately over the catheter

introduction site The strobe light positioned over the

puncture site, in turn, directs each individual ceiling light

to that specific spot on the catheterization table With one,

or several, of the lights mounted in the ceiling cephalad to

the image intensifier (and the lateral tube X-ray

suspen-sion arm) and with the remainder of the lights mounted

caudal to the image intensifier, excellent lighting is

avail-able to any area of the head, neck or arms as well as to

the inguinal areas These recessed lights do not interfere

with other ceiling-mounted equipment and take up “no

real estate”, but do represent a very expensive initial

investment

Blood oxygen saturation analyzer

The oximeter apparatus for the analysis of blood samples

for the immediate determination of oxygen saturations

is situated in the catheterization room and in very close

proximity to the catheterization table Most oxygen

analyzers are located on a very small, mobile table or cart The physician should be able to hand the syringewith the blood specimens for analysis directly to the technician/nurse for insertion into the analyzer and,

at the same time, the technician should not have to takemore than one or two steps between receiving the sample and inserting it into the analyzer The results from mostoxygen analyzers are displayed digitally on a very smallscreen on the analyzer A read-out of the saturation resultsalso should be clearly visible to the operator immediately,conveniently and on a large display in the catheterizationlaboratory A large, immediately available display of thedigital read-out of the oxygen saturation, the time of thesample and the location of the sample can be accom-plished with some “hard wiring” from an A-Vox™Oxygen Analyzer (A-VOX Systems, Inc., San Antonio, TX)

to a “slave” computer with a large CRT or flat panel display, which utilizes special computer software which

is now available from Scientific Software Solutions(Scientific Software Solutions, Inc., Charlottesville, VA).This provides a large, timed, instantaneous display ofeach oxygen saturation and its location as it is analyzed.The developed table of saturations, their time and locationcan be printed and used to verify the data that have beenverbally transmitted to the computerized catheterizationrecord

Ideally, these same data could also be transmitteddirectly from the oxygen analyzer to the electronic record

on the catheterization laboratory computer and be loggedinto the timed computer record without any verbal(shouted!), hand-written or manually typed transmission

of the information Unfortunately the small pediatric/congenital market has not been enough of an economicstimulus for any of the large manufacturers of physiologicequipment for the catheterization laboratory for them toprovide the communication necessary to incorporate thisalready available, digital information into their physio-logic monitoring/recording equipment

very small or debilitated patients regardless of the use of

other supplemental warming systems High environmental

temperatures also interfere with the cooling of any X-ray

generating equipment which happens to be positioned

within the room and provide another strong argument for

a separate equipment bay for this machinery

There are several separate patient-warming systems

commercially available for the catheterization laboratory

Separate, supplemental warming systems for the patient

are attached directly to the table or the warming

compon-ent is actually positioned on the catheterization table

The Bear Hugger™ hot-air warmers currently appear to

be the most suitable system for cardiac catheterization

procedures and they require a relatively fixed amount of

floor space immediately adjacent to the catheterization

table The heating mechanism with its blower is usually

positioned at the foot of the catheterization table A

con-necting tube from the blower attaches to a very long

U-shaped, sterile and disposable “paper tube”, the arms

of which run, unobtrusively, under the sterile drape

and along each side of the length of the patient The

warmed air is blown through these tubes around the

patient under the drapes The tubes do not interfere with

access to the patient nor do they show up on fluoroscopy

or angiograms

Several other patient-warming systems are available

which take up less fixed space around the table, but in

general, are less satisfactory for use in the catheterization

laboratory The K-Pad™ heating system utilizes a plastic

pad through which warm water is circulated The pad,

which is positioned under the trunk of the patient, is

attached by tubing to a small heater/pump, which is

placed on the catheterization table, under the drapes at the

foot of the table The K-Pad™ is not available nor suitable

for patients of all sizes and the tubing within the pad is

slightly radio opaque and, in turn, shows up on the

fluoroscopy and angiographic images, particularly in

smaller infants

Another, even less satisfactory alternative for warming

a patient is a floor-mounted “heating lamp” These take

up less space on the table and are very mobile, but they

must be positioned immediately adjacent to, and over, the

trunk of the patient, which always positions the lamp in

the working area of either the operator or the fluoroscopy

Like the lights on a floor-mounted stand, the heating lamp

extending over the trunk of the patient represents a

con-stant potential for contamination of the sterile field Of

even greater concern is it that, in order to warm a patient

through a very focused heat source from above, the

heat-ing lamp must generate a relatively high heat and must be

positioned fairly close to the patient’s skin, the

combina-tion of which creates a real potential for actually burning

the latter The use of this type of lamp must be monitored

very closely to prevent this occurrence

Angiographic injector

The angiographic injector should be capable of beingattached to the angiographic catheter from either side ofthe catheterization table, from the top or bottom end of thetable and from any catheter introduction site The injector

syringe must always be angled downward when it is

con-nected to the hub of a catheter or connecting tubing for aninjection The downward angle forces any air which might

be trapped in the injector tubing or injector syringe to rise

to the back end of the injector syringe When the injectorsyringe is attached directly to the catheter hub, the injector

head is always positioned above the level of the hub of the catheter in order to assure that the tip of the injector

syringe is pointing downward

Fortunately, the “injector head” of the modern MedRad(MedRad, Inc., Indianola, PA) and Liebel-Flarsheim(Mallinckrodt Inc., Hazelwood, MO) angiographic injec-tors can be separated from the large, bulkier, control apparatus of the injector This allows the injector head

to be mounted separately and away from the control unit.Mounting the injector on a long, movable, ceiling-mounted arm positions the injector head well above thesurface of the catheterization table and allows it to bemoved to any location about the table A ceiling-mountedinjector does not occupy any floor space and there is lessdanger of the sterile field or the operator being contam-inated when the injector is being attached to, or while it isattached to, the catheter The separate control unit can bepositioned across the catheterization room away from thecatheterization table or, preferably, even in a separate, butadjacent control room

A less satisfactory arrangement is to have the separateinjector head mounted on a mobile floor stand However,the floor stand occupies valuable floor space wherever it ispositioned and it must also be moved about the room andpositioned immediately adjacent to the catheterization tablefor injections This positions the stand very close to the side

of the patient and necessitates that the injector extendsover, and very close to, the sterile field With a rigidattachment to the floor stand, the injector head cannot beraised much above the level of the catheter hub in order tokeep the tip pointing downward Some of these disadvant-ages can be obviated by the use of very long connectingtubes between the injector syringe and the catheter

Adjustable radiation protection screens

In addition to the regular use of lead aprons and optimalX-ray techniques, supplemental X-ray protection screensshould be used during every catheterization procedure.Most of the radiation to the operating physician originatesfrom the scatter, which emanates out of the patient’s body

above the catheterization table The most effective way of

minimizing this radiation to the operator is by the use of a

leaded glass screen placed between the patient’s body and

the operating physician The preferred screen for the

pro-tection of the operating physician is suspended on a long

articulated arm from the ceiling above the catheterization

table In this way the screen, covered with a sterile,

trans-parent drape, is moved between the patient and the

opera-tor without occupying any “real estate” on the floor of the

room and without contaminating the field

Similar protective leaded glass screens are available on

floor mounted stands, which move on casters; however,

the floor screens occupy valuable floor space and when

used near the catheterization table, interfere with

angula-tion of the X-ray tubes Large, free standing, transparent,

leaded glass X-ray screens, mounted on casters, are useful

for the protection of personnel not working directly at the

table The additional personnel who benefit the most from

these screens include the anesthesiologist, the circulating

nurse/technicians and respiratory therapists

Cardiac output computer

Determination of the cardiac output is often required

during the catheterization of pediatric and congenital

heart patients Although a precise cardiac output is not

necessary for calculating relative shunts and obvious

gradients, when the calculations of absolute flow and

resistances are necessary, an accurate cardiac output

be-comes mandatory Our cardiac catheterization

laborat-ories now use a thermodilution technique with a small,

dedicated, Dualtherm™ Cardiac Output Computer (B

Braun Medical Inc., Bethlehem, PA) designed specifically

for calculating thermodilution cardiac outputs The

ther-modilution apparatus is relatively small and is mounted

on a small mobile cart When a cardiac output is to be

determined, the computer is connected to the specific

thermodilution catheter (B Braun Medical Inc.,

Beth-lehem, PA) on the catheterization table with a sterile,

reusable cable, which extends directly from the computer

to the catheter This small cart is moved close to the table

for cardiac output determination and is parked well away

from the catheterization table when not in use

“In-room” consumable equipment storage

The great bulk of the consumable equipment, including

the back-up supply of the most frequently used items, is

stored in a separate, dedicated storage room, which is

situ-ated immediately adjacent to the actual catheterization

room At the same time, a limited supply of multiple sizes

of very frequently and repeatedly used sterile consumable

items including percutaneous needles, a variety of guide

wires, sheath/dilator sets, syringes, the most frequently

used catheters and even gloves are stored directly in the

catheterization room, but in mobile carts While all of theconsumable equipment could be stored in the adjacentstorage room, the repeated retrieval of very frequentlyused items from a separate, even though adjacent room,during the case, reduces the functional efficiency of thelaboratory very significantly

Storage of the “high use” expendable materials actuallywithin the room maximizes the efficiency for the frequentretrievals Specifically configured, mobile storage cartsprovide the most effective vehicle for this in-lab storage ofthe frequently used consumables These can be moved inand out of the room for cleaning, for restocking with newsupplies or when the particular items on that cart are notbeing used at all These carts can also be moved easily toaccommodate a reconfiguration of the arrangement of the room according to the various introductory sites forthe catheters or according to the type of procedure beingperformed

The mobile storage carts maximize the usable space

of the room as opposed to the traditional, fixed cabinetsalong the walls of the room Any fixed, built-in cabinetsfor storage within the catheterization room represent

“wasted” floor space, which is lost permanently and not be “adjusted” Each row of fixed cabinets or countersreduces the functional width or depth of the catheteriza-tion room by at least three feet and reduces the total floorspace of the catheterization room by this width times the length of the wall(s) covered with cabinets! Built incabinets do not allow even minor reconfiguration of theroom for different procedures

can-“Mobile” equipment stored outside of the catheterization room

There are other pieces of mobile equipment that areshared between several catheterization rooms and storedwithin the general area of the catheterization laboratory,but preferably just outside of the actual catheterizationroom Each piece of this equipment requires space forstorage outside of, but adjacent to, the actual catheteriza-tion room and, when the equipment is in use, additionalspace must be provided for it in the catheterization roomitself Among this ancillary equipment are included a sep-arate, but constantly available, 2-D echo machine, a radiofrequency generator, an oxygen consumption apparatuswith its constant air withdrawal system and several

“hoods”, an echo console for intravascular ultrasound(IVUS), transesophageal echo (TEE) and/or intravascularecho (ICE), a Laser™ generator and possibly a cardiac

“mechanical assist” device When used, most of thesepieces of equipment must be positioned immediatelyadjacent to the catheterization table At the same time, thelocation of this equipment while it is being used shouldnot interfere with the catheterizing physician’s access to

the patient or the overall mobility within the room This

requires a greater overall planned width or depth to the

room in order to prevent severe side-by-side crowding at

the tableside

2-D Echo machine

A 2-D echo machine capable of transthoracic scanning of

the pericardial space should be available in the

catheter-ization laboratory immediately for emergency situations

This does not have to be the latest nor the most

sophisti-cated echo machine available but it must be functional

This echo machine is required in addition to, and separate

from, the TEE/ICE console, which usually is a special

console utilized specifically for TEE and/or ICE and is

brought to the catheterization laboratory only when TEE

and/or ICE is/are used Much of the time, the TEE/ICE

machine may be needed elsewhere in the hospital and, in

turn, may not be available for some time or be physically

far from the vicinity of the catheterization laboratory The

separate, always available 2-D echo machine is primarily

for screening patients who deteriorate either acutely or

unexpectedly This is particularly important when

screen-ing for suspected cardiac tamponade The added time

needed to transport an echo machine to the

catheteriza-tion laboratory from an area outside of, and remote from,

the immediate catheterization area represents a delay in

confirming a diagnosis, which could easily represent the

difference between a successful and an unsuccessful

resuscitation

Radio frequency generator

Pediatric cardiac catheterization laboratories now require

a dedicated radio frequency (RF) generator, which is

de-signed specifically for the perforation of tissues Although

this unit may be used only 6–12 times per year, the infants

in whom an RF generator is used are not “scheduled” and

often have a critical time window for their treatment The

BMC Radio Frequency Generator (Baylis Medical Co Inc.,

Montreal, Canada), specifically for perforation, is quite

small and can be stored outside of the actual

catheteriza-tion room when not being used When used in any

particu-lar procedure it is placed on a small, temporary cart

adja-cent to the catheterization table and connected to the RF

catheter (Baylis Medical Co Inc., Montreal, Canada) with

a sterile reusable cable

Oxygen consumption apparatus

The MRM-2 Oxygen Consumption Monitor (Waters

Instruments Inc., Rochester, MN) for measurement of

oxygen consumption is a gas analyzer in conjunction with

several different hoods and a vacuum pump/blower used

to draw air through the hoods In most laboratories, theapparatus is used infrequently and, as a consequence, is(should be) stored in an adjacent area, out of the catheter-ization room The apparatus is cumbersome; it covers thepatient’s head, neck and upper thorax and is fairly disrup-tive to the usual catheterization procedure When an oxy-gen consumption determination is to be performed on apatient during a catheterization procedure it is plannedahead of time and the specific arrangements are made forthe oxygen consumption measurement when the patient

is being placed on the catheterization table The patient’shead and neck are positioned on a flat surface on thecatheterization table with no pillow beneath their head.There can be no catheter lines entering the neck and thepatient cannot be intubated or receiving oxygen or generalanesthesia while oxygen consumption is being measured

Intravascular ultrasound and intracardiac echo equipment

Currently intravascular ultrasound (IVUS) and diac echo (ICE) imaging are used frequently in many pediatric and congenital catheterization laboratories Theparticular consoles from Acuson, Mountain View, CA orBoston Scientific, Natick, MA, which are used for thisimaging are quite large The consoles are usually storedout of the actual catheterization room and brought intothe laboratory only when needed for a specific case Thecatheter for ICE is a 10–11-gauge French catheter and usu-ally is introduced from a femoral vein, while the cathetersfor IVUS are smaller and can be introduced into a vein orartery from a femoral or jugular access site and can beintroduced from either arm The catheters are usuallyattached to their respective console with a long connectingcable within a long sterile sleeve The physician operatingthe console is not necessarily the catheterizing physicianwho is maneuvering the catheter As a consequence, themachines (consoles) for these procedures usually do nothave to be immediately adjacent to the catheter introduc-tion site, but do require a relatively large space, relativelyclose to the catheterization table in the general area wherethe imaging catheter is introduced Like the TEE, a remote

intracar-or slave monitintracar-or is usually necessary in intracar-order fintracar-or thecatheterizing physician to visualize the intravascular echoimages conveniently

Laser™ generator

A Laser™ generator (Spectranetics, Colorado Springs,CO) is used for lead extractions and some purposeful per-forations It is another very large piece of equipment,which is used in a pediatric/congenital cardiac catheter-ization laboratory only occasionally and, when moved intothe room, requires significant additional space adjacent to

the catheterization table The Laser™ generator is stored

outside of the catheterization room or even away from the

laboratory as a shared piece of equipment between several

services or even institutions The use of the Laser™ is

scheduled well ahead of time and the generator is moved

into the laboratory for the specific procedure Special

pre-cautions for eye protection are required for all personnel

who are, or might be, in the room for the procedure

Considerable rearranging of the equipment in the room is

required during these isolated and rare circumstances

Extra cardiac membrane oxygenator (ECMO) or

other left ventricular assist device (LVAD)

An even more rarely used piece of very large and

cumber-some adjunctive equipment which may become more

common and even essential in the future catheterization

laboratory is one of the cardiac assist devices including an

ECMO apparatus, an intra-aortic balloon pump or even

an LVAD When an assist device is necessary, it likely

would be as an emergency Although the equipment for

these procedures would have to be moved from the

oper-ating room or intensive care area, it would not be

expedi-ent to have to move other equipmexpedi-ent which is being used

in the catheterization laboratory out of the laboratory, or

to have to rearrange the catheterization laboratory very

significantly in order to bring these large pieces of

emer-gency equipment to the patient rapidly during such an

emergency A potential physical “corridor” to the table,

and place for this equipment, should be considered ahead

of time when a catheterization is planned on a patient who

might be a potential candidate for such therapy

Electrophysiology equipment

The pediatric/congenital electrophysiologic (EP)

labora-tory contains additional very large pieces of equipment

which, unlike the catheterization table itself, are not fixed

structures in the room, but, at the same time, are not

par-ticularly mobile and take up considerable additional fixed

space This equipment varies with each EP laboratory, but

at a minimum includes a separate computer and monitor,

a separate recorder, a stimulator, a radio frequency

gener-ator for ablations, multiple additional CRT monitors and

additional mobile storage cabinets for the frequently

used, special EP consumables The Laser™ generator for

lead extractions is more likely to be used and stored in the

EP laboratory The extra EP “capital” equipment often has

a space requirement equivalent to the space of a separate

control room Usually this equipment is housed in, and

used directly within the catheterization room This extra

space should be included in the basic design of the

catheterization room which is to be used for

a separate control room for each catheterization room, alarge room for the storage of the majority of the consum-able equipment, a separate electrical equipment room or

“bay” for the X-ray generators, controls and high-tensionswitches, a patient holding/preparation area, an adminis-trative support area, a record/angio review/work area,

an on-site storage area for “active” patient records andangiograms, a biomedical service/supply area and a sep-arate procedure room for procedures other than X-raywhich require monitoring (e.g phlebotomies, thoracocent-esis, transesophageal echocardiograms)

Control room

The control room houses the physiologic monitoringequipment, computer recorder and the controls for the X-ray system for each specific catheterization room In addi-tion, each control room contains remote monitors of theCRT screens which are in the catheterization room, thecontrols for the angiographic injector, the computer(s)which is/are connected to the hospital system, the digitalX-ray recording system, a digital disk copier, printers forphysiologic records, the computer log of the procedure,and hard-copy printers for X-ray images, all with ade-quate space for at least two nurses/technicians to functioncomfortably An area 10 to 11 feet wide and as long as the width of the catheterization room (e.g 10 × 24 feet)provides a reasonable sized control room with room forsome fixed counters and cabinet space in addition to themonitoring equipment In addition to a good view of theentire catheterization room, including the entire catheter-ization table, and clear voice communication between thecatheterization room and the control room, the personnel

in the control room should have direct and easy physicalaccess into the catheterization room

The control area preferably is not situated within the

actual catheterization room The control/monitoring/recording equipment takes up a large amount of valuablefloor space, which should not be taken from the actual

catheterization room The control room equipment

generates noise, accumulates dust and is operated more

effectively in a clean, but non-sterile, environment In

addition, when the control room equipment is located

within the catheterization room, it exposes the nurses/

technicians who operate it to extra and unnecessary

radiation At the same time, the control room must be

immediately adjacent to the catheterization room The

ori-entation of the catheterization table diagonally across the

catheterization room facilitates a view of the entire length

of the patient on the table whether the control room is

directly at the end or along the side of the catheterization

room The control room usually is not a sterile area and

can have additional space in it, which serves as an

obser-vation area for consultants/visitors

A shared central control room between two or more

catheterization rooms is seen occasionally, but is not an

optimal arrangement Except for a questionable economy

of space, there is no justification for a combined or shared

control room None of the actual electronic control

equip-ment in the control room is shared between separate

catheterization rooms Much of the communication

between the separate catheterization rooms and the

con-trol room and within the concon-trol room is verbal When

the control equipment and personnel from two or more

laboratories are grouped together in one room, there

are continual distractions, the communication becomes

confused and the working environment becomes very

congested and noisy

Consumable equipment storage room

The majority of the consumable equipment (catheters,

introducers, wires, dilation balloons, special devices, etc.)

is stored outside, but immediately adjacent to, the actual

catheterization room For a laboratory performing

thera-peutic catheterizations on pediatric and adult congenital

heart patients, this requires a huge amount and variety

of consumable equipment which, in turn, requires a very

large storage space, which is equal in size to the optimal

sized catheterization room (roughly 32 × 24 feet)

Fortu-nately two, or even three, separate catheterization rooms do

not require significantly more consumable equipment and

additional storage space for the consumable equipment

than a single laboratory If there is more than one

catheter-ization room, it is most efficient to have a single storage

room for the consumables adjacent to, and connected to,

all of the separate catheterization laboratories (rooms)

with convenient access to each of the laboratories Because

of the large amount of very expensive consumable

ma-terial required for a pediatric/congenital catheterization

laboratory, the storage area must be absolutely secure

The storage room requires an organizational plan or

arrangement for inventory control which (1) keeps track

of each item used to facilitate the expedient reordering ofused items and, (2) obligates the use of the older itemsbefore newer, more recently acquired items in order toavoid the problem of having to discard new and unuseditems because of material or sterility expiry dates Thisorganization of the inventory is even more critical whenseveral or more catheterization rooms are drawing sup-plies from the same storage source

A catheterization laboratory should have both a bloodgas analyzer such as an ABL 700 Radiometer (Radiometer,Copenhagen, Denmark) and an activated clotting time(ACT) machine (Hemo Tec, Inc., Englewood, CA) Both ofthese machines can be shared between several or morecatheterization rooms These machines are fixed in loca-tion and when shared, they are housed conveniently in acentral consumable storage area, which is adjacent to all ofthe actual catheterization rooms This equipment must

be in close proximity to each catheterization room but,preferably, must not be within the catheterization roomitself Under usual circumstances this equipment is usedonly two or three times during an entire catheterizationprocedure Both the blood gas and ACT machines requireregular maintenance and calibration by biomedical per-sonnel who normally function more proficiently in a non-sterile environment When these machines are not in theactual catheterization room, any maintenance/calibrationcan be performed on them while a catheterization is inprogress Rarely, blood gas machines are used to calculateall of the blood oxygen saturation determinations In thatsituation, the blood gas machine should be physically inthe catheterization laboratory

A separate, X-ray equipment room or “bay”

It is now essential that modern X-ray generators and X-ray

power supplies are housed in a dedicated equipmentroom, which is completely separate from the catheteriza-tion room There no longer is a place for the cabinets for the X-ray generators, controllers and high-tension

“switches” to be located within the actual catheterizationroom In addition to the physical space occupied by thehigh-tension generators and other X-ray electronic equip-ment, this equipment requires a separate and efficientrefrigeration/air conditioning unit to allow continuous,extra and extreme cooling of the X-ray and other electricalcomponents in order to counteract the excessive heat generated by it The cool environment is essential for theday-to-day stability and operation of the sensitive equip-ment and in order to maintain the durability of the very expensive electrical equipment When the electricalequipment is situated in the catheterization room, an envi-ronmental temperature which is cool enough to keep theequipment adequately cooled is far too cold to maintainthe body temperature of a patient

Although the “equipment bay” is a separate room,

because of the limitations of the maximal lengths of the

high-tension cables connecting the X-ray tubes to the

gen-erators, it must also be in close proximity to the actual

catheterization laboratory Assuming the “geometry” can

be solved for situating more than one catheterization

room adjacent to the equipment bay, a single equipment

bay can house the generators and power supplies of two

or more catheterization rooms while using the same

addi-tional cooling system The equipment bay needs a lot of

wall space for the modern digital electronics so that a

relat-ively long but narrow room, for example 10 × 32 feet, will

suffice to hold the heavy electronic equipment for two

biplane catheterization rooms (Siemens Medical Systems,

Inc., Iselin, NJ) as well as the extra cooling equipment

In addition to the cooling requirements, even the latest

digital and computerized catheterization laboratory X-ray

generating equipment still takes up a large amount of

space and, if positioned within the actual catheterization

room, would reduce its functional width by at least two

feet in depth along one entire, long wall When the

genera-tion equipment is within the sterile catheterizagenera-tion room,

access to the equipment for maintenance or even minor

resetting of circuits is restricted to times when the room is

not in operation Like the electronic equipment in the

con-trol room, the X-ray generating equipment has huge areas

for attracting and collecting dust, which is not acceptable

in a “sterile” working catheterization room

Preparation, holding and recovery area(s)

for patients

Patients do not enter directly into the cardiac

catheteriza-tion laboratory from “outside”, nor do they go directly

home after a catheterization With many pediatric and

congenital heart cardiac catheterizations now being

performed as outpatient or “day-surgery” procedures, an

area is required for the admission of the patients for the

catheterization procedure, their preparation for

catheter-ization and the administration of premedications When

the catheterization laboratories operate adjacent to, or in

conjunction with, the cardiovascular operating rooms,

the same preparation/holding area can be used to admit

the patients for both the catheterization laboratories

and the operating rooms The total size of the “holding

area” depends upon the number of procedure rooms

(catheterization labs or operating rooms), which are being

supported

Each bed space in a “holding/admitting” area should

be capable of monitoring and recording several leads of an

electrocardiogram, a pulse oximetry display, a display

of the patient’s body temperature and the capability of

displaying at least one pressure monitoring line The

physical space of each “holding bed” must comply with

standards for recovery room beds Each bed requirespiped in oxygen, compressed air and suction The holdingarea must have a separate “crash cart” including emer-gency cardiac medications, intubation and temporaryventilation equipment as well as a cardiac defibrillator.All of the facilities and equipment for drawing blood sam-ples as well as starting and maintaining intravenous linesmust be available in the holding area All of the beds can

be in one open area, but must be separated from eachother by at least curtains or screens Since some patientsmay remain in the area for a relatively long period of timeawaiting their catheterization or surgery, a television

or “play station” is made available for at least half of the beds

The number of beds and the size of this area, obviously,depend upon the number of catheterization rooms (andoperating rooms if the area is shared), any function of thearea besides admitting and holding, and the total number

of patients expected through the area per day For patientpreparation and premedication, one bed per catheteriza-

tion procedural room and one bed for each operating room

are sufficient This allows for the simultaneous tion at the beginning of the day of all of the “first” patientsfor each of the procedural rooms and allows each proce-dural room to start at approximately the same time whendesired Patients who are scheduled for catheterization(or surgery) as second, third or later cases are scheduled toarrive at the holding area later according to a staggeredschedule This allows a bed for each patient, time to admiteach patient comfortably, prepare them for the procedureand to have them totally prepared and sedated by the timethe procedure room is ready to start

prepara-A four to six hour recovery/observation period ismandatory immediately post-catheterization for cardiaccatheterization patients The patient should have closemonitoring by experienced nurses during that time immediately after a cardiac catheterization Ideally, thismonitoring is accomplished in a cardiac recovery area

or cardiac intensive care unit However, if the cardiaccatheterization laboratory is in a location remote from thecardiac recovery/intensive care units, the holding areacan be adapted to serve as an observation/recovery areafor the patients post-catheterization With an adequatenumber of beds and the space and monitoring equipment

to be used for patient recovery post-catheterization alreadyestablished, the same area used for the patients’ admis-sion can be expanded to a recovery area In that circum-stance, because of the overlap of the patients arriving fortheir procedures with the patients who are recovering, the

“recovery” beds in the area should be separated from the

“admission” beds more solidly than with just curtains

A recovering patient who is uncomfortable, vomiting

or having more serious problems, is extremely upsetting and frightening to a patient who is about to undergo “the

same” procedure! When the holding area is used for

post-catheterization recovery, the nursing staff is larger, the

nurses need additional training and experience in the

recovery of catheterization patients and the functioning

“hours” of the holding area must be extended and

very flexible according to the anticipated procedures for

the day

Administrative and general support areas

A liberal amount of additional space is required within the

general catheterization area for the general administrative

support of the catheterization laboratory This support

area includes the working areas for the catheterization

laboratory manager and secretarial/administrative

assist-ants They should be located in close proximity to the

actual laboratory in order to support the

minute-to-minute activities of the laboratory including the changes

in scheduling and assignments during each day The

administrative support area also provides a work area for

the nurses, technicians and physicians to review and

com-pile the catheterization records and angiograms, space

and the equipment for copying these materials and space

for the temporary storage of, at least, the most current and

“active” catheterization records and angiograms For the

support of two or more laboratories, this requires working

space for two or more personnel This area can be

relat-ively long and narrow in order to be positioned

immedi-ately adjacent to the catheterization laboratories, for

example 10 to 11 feet by 32 feet in length

The catheterization laboratory area must have adequate

and convenient toilet facilities, which include sinks and a

shower along with secure lockers and changing space for

all of the personnel working in the catheterization area

The personnel should not have to leave the general area of

the catheterization laboratories to use the toilet or

chang-ing facilities Easy access to a supply of “scrubs” in a

con-venient changing/locker area within the catheterization

suite encourages the personnel to change into scrubs

while in the catheterization laboratories, but, at the same

time, encourages them not to wear the scrubs out of the

hospital

The overall cardiac catheterization area needs a

separ-ate break or relaxation area for all of the personnel who

work there The personnel in the catheterization

labor-atory work in a continually stressful atmosphere and,

frequently, at a continual and frantic pace At least a

short intermittent break out of the catheterization room

improves the working atmosphere in the room When this

“break room” is still within the area of the catheterization

suite, it allows the personnel to have time out of the actual

rooms without loosing “transit” time to and from a break

area and without the personnel having to change out of

their laboratory scrubs

Cine/angio/data review area

Each catheterization suite requires an area for the cians to review and analyze the data and the angiogramsfrom the current catheterizations The review area shouldhave space to accommodate up to four or five physicians

physi-at a time as well as a large counter space for the reviewand measurement of the paper tracings of the recordedpressures, which when stretched out extend for severalmeters The review area requires at least one computer,which is in communication with the catheterization labor-atory as well as the information systems of the hospitalincluding the hospital X-ray and echo systems This (or these) computer(s) also should be in communicationwith the on-line, digital storage system for the digitalangiograms from the catheterization laboratory

The review room requires specific and usually separateequipment for the review of “outside” angiograms as well

as those generated in the catheterization laboratory itself.The common transferable, digital media at the presenttime is the DICOM encoded compact disk (CD) Thisrequires a digital viewer/review station, which can readall medically encoded DICOM digital data Although allmajor medical manufacturers supposedly comply with asingle DICOM standard, occasionally separate software isrequired in the CD reader or a completely separate com-puter/review station is necessary to read CDs from differ-ent systems/manufacturers Since many of the previous,older, angiographic studies on the current patients wererecorded on cine film and some existing cardiac catheter-ization laboratories are still recording on cine film, thereviewing area requires a functioning cine film viewer(Tagarno of America, Inc., Dover, DE)

The review area must have some space designated for the storage of the catheterization reports and angio-cardiogram of patients who are currently hospitalized,

or who will be hospitalized in the near future A copyingmachine for records, catheterization diagrams and digitalangiograms improves the efficiency of the area and helps

to keep permanent records intact

Biomedical support area

With the total dependence in a modern catheterizationlaboratory upon the large variety of both simple and very complex electro-mechanical equipment, all cardiaccatheterization laboratories are equally and totally depend-ent upon biomedical support being readily available inorder to operate the cardiac catheterization laboratoriesdaily and continuously Ideally the biomedical personnelfor the cardiac catheterization laboratory are a part of thecatheterization laboratory personnel, and their primaryresponsibility is to the catheterization laboratory Thereshould be adequate space in the vicinity of, or actually in,

the catheterization laboratory suite for the biomedical

per-sonnel to work on the mobile equipment The biomedical

area must include space to store the testing and repair

equipment as well as pieces of frequently needed and

essential “spare” equipment When there is more than one

catheterization laboratory or other “high-intensity

electri-cal areas” (operating rooms, intensive care areas) in close

geographical proximity, there is adequate justification for

specific biomedical engineers who are knowledgeable in

that particular equipment to be assigned to the

catheter-ization laboratories

Any delay in the investigation and repair of an

equip-ment malfunction, no matter how minor, results in

an equivalent “down”, or “inactive time” for the room,

which includes three or more salaried nurses/technicians

and one or more physicians who would be working in that

room A malfunction of a piece of equipment often

requires a “repair” which is as simple as resetting a relay

or switch and actually takes only seconds for a

know-ledgeable person to correct At the same time, the relay

may be located in a “high-tension” cabinet containing

very complex electronics and, as a consequence, should be

manipulated only by experienced biomedical personnel

An otherwise short delay is prolonged unnecessarily

when the biomedical support who is capable of the simple

“repair” or “resetting” is located any distance (and time)

from the catheterization area An active, fully scheduled,

cardiac catheterization laboratory cannot afford any

significant “down time” Any equipment failure during

operating hours results in the rescheduling of the patients

with a frequent “domino” effect on other patients and

ser-vices throughout the hospital, in addition to the obvious

costs in personnel “down time”

A separate “minor procedure” room

Depending upon the size of the cardiology service, there

are a variable number of procedures which require

mon-itoring, sedation and, occasionally, even general

anesthe-sia These procedures include phlebotomies with colloidal

volume replacement, “tilt table” and other vaso-motor

electrophysiologic testing, transesophageal

echocardio-graphy under general anesthesia, pleural taps and drainage

with or without chest tube insertion, some pericardial

taps and even some difficult intravenous or intra-arterial

lines The “interventional”, “intensivist” or “catheterizing”

physicians frequently perform these procedures Although

these procedures have been, and can be, performed in

catheterization laboratories, they generally do not require

all of the elaborate equipment and personnel of a

catheter-ization laboratory

Ideally, a separate “procedure room” is available in

the immediate area of the catheterization laboratories/

holding area This room needs to be large enough to

accommodate the procedure table, a sterile work table forthe physician, any ancillary large equipment (e.g a TEEmachine, an anesthesia machine) and area for personnel tofunction in the room The procedure room should havemonitoring available with the capability of permanentrecording of the ECG, pulse oximetry, a periodic recyclingcuff blood pressure apparatus and at least one pressuretransducer and recording channel for an indwelling linewhen desired Piped in oxygen, compressed air and suc-tion are essential The procedure table in this room is

an operating type of table, capable of tilting or there is aseparate “tilt table” which can be moved into the room.The procedure table is lit with a high-intensity, ceiling-mounted, mobile “operating room” light This roomshould have a mobile equipment cart to hold the consum-ables for any procedure being performed The procedureroom must have immediate access to a separate “crashcart” with intubation equipment, resuscitative drugs and

fluids and a defibrillator If the procedure room is ately adjacent to the “holding” area, the emergency cart is

immedi-shared with the holding area Patients who are treated inthis procedure room need admitting and frequently arecovery time similar to a catheterization patient

Film processing room

A film processing room (area) is no longer necessary in

a cardiac catheterization laboratory with digital X-rayequipment A film processing room is still necessary inlaboratories with older X-ray equipment which are usingcine film as the recording medium Although the image isproduced by X-ray energy, cine-angiography film is aphotographic film and is processed in a separate proces-sor and with completely different techniques from theprocessing of X-ray film Cine film processing is complex,time consuming, space occupying and environmentallypolluting, all of which justifies upgrading cine film X-rayequipment to a digital system

A film processing area includes not only a room for thefilm processor, but also a dark-room and a separate room

to store the processing chemicals The film processors arefairly compact but very complicated and require plumb-ing attachments from the chemical tanks and separateattachment to a special drainage system for the highlyacidic and toxic developing chemicals The processorrequires constant maintenance in order to obtain the opti-mal processing of each roll of film The daily maintenanceincludes adjusting the composition and temperature ofthe chemicals, assurance that all of the pumps and drivesare functioning properly, and the cleaning of the multipleseparate tanks and rollers in the processor In addition tobeing consumed by the processor, the processing chemi-cals deteriorate with time and must be changed regularlyregardless of the use of the processor Possibly by the time

this book is published, film processing in the

catheteriza-tion laboratory will be delegated to the historical annals!

Catheterization laboratory personnel

Physicians

The medical director of the pediatric/congenital cardiac

catheterization laboratory should be a pediatric

cardiolo-gist who regularly performs procedures in the

catheter-ization laboratory The ultimate responsibility for the

proper equipment and the necessary personnel in the

labor-atory and, in turn, the smooth operation of the laborlabor-atory,

is that of the medical director of the laboratory The

physi-cian director must have the full support of the hospital

The number of cardiologists who perform

catheteriza-tions and their qualificacatheteriza-tions depend upon the number

and type of procedures being performed in the

catheter-ization laboratory

A “simple” diagnostic catheterization procedure in a

congenital heart patient can be performed by a single

pediatric/congenital cardiologist with well trained and

experienced support staff The physicians and staff, for a

diagnostic catheterization, do not have to have special

training in therapeutic/interventional catheterization

proced-ures, but should be experts in the anatomy and

hemody-namics of congenital heart disease

Most complex interventional (therapeutic)

catheteriza-tion procedures performed on congenital heart patients

should be performed by pediatric cardiologists with extra

training in interventional catheterizations or with

extens-ive experience in the catheterization laboratory and

par-ticularly with these procedures New devices/procedures

being introduced require even experienced interventional

cardiologists to have some special individualized

mentor-ing by a physician experienced in the procedure before

beginning to use the new device/procedure Most

pedi-atric cardiologists who are entering the field of

interven-tional/therapeutic catheterizations should and do take at

least a year of additional and specific training in

interven-tional catheterization procedures2

The more complex the catheterization procedure which

is to be performed is, the more highly trained the

physi-cian(s) and catheterization laboratory staff must be for

performing that procedure Also the more complex the

procedure is, the more experienced physicians and highly

trained support nurse/technicians are required to be

scrubbed and circulating during each procedure For

example, to perform complex catheter manipulations or

even a “simple” balloon dilation procedure, there are

mul-tiple exchanges of catheters and wires with long lengths of

guide wire extending out of the catheters which must be

controlled to prevent their falling off the table During the

single balloon inflation a knowledgeable individual trols the position of the catheter/wire while a secondknowledgeable individual inflates and deflates the bal-loon The implant of two stents simultaneously represents

con-an extreme of additional staffing needs for skilled staff.Two knowledgeable physicians maintain the stent/balloons precisely in place while two additional, trainedindividuals simultaneously control the inflation of the

two balloonsai.e four skilled individuals scrubbed for one

procedure Working with insufficient numbers of nel or inadequately trained personnel prolongs a proced-ure significantly and increases the likelihood of adverse

person-events or serious complications The same procedure can

be accomplished with fewer and less well-trained nel scrubbed, but only with the substitution of a great deal

person-of luck for skill and with an increase in the likelihood person-of anunsuccessful procedure or a procedure which results inserious complications! The problems encountered are ininverse proportion to the skill of the personnel and thenumber of skilled personnel involved with the procedure

Non-physician catheterization laboratory personnel

Most pediatric/congenital cardiac catheterization atories require three, if not four, professional nurses orcatheterization laboratory technicians to operate a cathe-

labor-terization room efficiently The total number of nurses/

technicians for an entire catheterization service mustinclude not only the precise number of skilled individuals

to operate each catheterization room, but enough extrapersonnel to account for illness, vacation, educational andcompensatory time of the regular staff Because of theextensive extra training each individual requires to func-tion effectively as a catheterization nurse/technician in apediatric/congenital cardiac catheterization laboratory,extra personnel cannot be pulled from other areas or from

a general “pool” of personnel in the absence of one of theregular catheterization laboratory nurses/technicians Thelaboratory itself must have its own pool of trained nurses/technicians to pull from This is easier to accomplish whentwo or more catheterization rooms are operating in theoverall pediatric/congenital cardiac catheterization unit.The nurses/technicians who work in the cardiac cathe-terization laboratory have a background of registerednurses, practical nurses, radiographic or pulmonary tech-nologists or have graduated from specialized cardiaccatheterization or cardiopulmonary technician schools.Regardless of their background, almost all nurses/tech-nicians starting in a pediatric/congenital cardiac catheter-

ization laboratory require at least six months of orientation

(on the job training) working in the catheterization atory under the supervision of the already experienced personnel in the laboratory To work in a pediatric/

labor-congenital cardiac catheterization laboratory further,

ex-tensive training/orientation is necessary, even for a nurse/

technician who has extensive catheterization laboratory

experience in an adult catheterization laboratory

All of the nursing/technician personnel in the pediatric

catheterization laboratory should be “cross trained” to

perform all of the nursing/technician functions within the

catheterization laboratory In that way, any combination

from all of the individuals in the laboratory pool can be on

call together and in the unexpected absence of any one

individual, any other nurse/technician is trained in, and

can assume, the missing person’s functions This requires

additional in-house training of new personnel in order to

make them experts in areas and procedures which were

not included at all in their pre-pediatric catheterization

laboratory, background training

Because of all of the extra training, the complex and

potentially dangerous procedures performed daily on

very sick patients and, in turn, the very high degree of

responsibility and stress imposed on each individual, the

cardiac catheterization laboratory personnel represent

an elite, special group The efficient completion of every

procedure depends upon each nurse’s/technician’s skills,

on their cooperation with each other and the physicians

and on their willingness to work together as a team

The minimum number of nurses/technicians required

for each cardiac catheterization room is determined by the

physical layout of the laboratory, the organization of the

personnel, and the amount of nurse’s or technician’s work

which the physicians themselves perform Reducing the

required or even optimal number of nurses/technicians

available during a case represents a false economy of bodies

at the increased expense of an inefficiency of function When

one nurse/technician is missing in a catheterization

labor-atory, that individual’s particular jobs are performed by

one of the remaining personnel in the room who,

how-ever, already has their own, assigned jobs and functions

The two or three nurses/technicians and the one to three

physicians still in the room performing a procedure when

one of the support personnel is missing, must wait several

or more minutes for a particular procedure to be

per-formed or for an item to be procured while the individual

who normally performs that procedure or function is now

performing the job of the missing person Each delay of

two minutes as a result of the absence of one individual

results in a minimum of 12 minutes of total personnel time

lost during the operation of the catheterization laboratory!

For example, in the absence of a circulating nurse, the

nurse who operates the manifold must leave the manifold

to retrieve an item of consumable equipment in the

adja-cent storage room During the time the manifold nurse

is out of the room, the operator cannot flush the catheter if

he draws a sample, cannot switch to or from the pressure/

flush line or balance the transducer to record a pressure

and cannot administer medications until the manifoldnurse returns These lost segments of time for all of thepersonnel performing the case are multiplied many foldduring every case when one essential person is missing.The repeated waiting time of the multiple individualsadds up to much more than enough time to account for thesalary of the “extra” individual who is missing!

Emergency and off-hour cardiac catheterizations stilloccur quite frequently in a busy pediatric or congenitalcardiac catheterization laboratory A full complement ofnurses/technicians for one catheterization room must beavailable on call Although most emergency catheteriza-tions are not as extensive or as prolonged as the usualscheduled procedures, emergency cases are performed

on the very sickest and most precarious patients Thesepatients require the most intensive medical and most

timely management As a consequence, the emergency

cases should not be undertaken short handed with lessthan a full complement of nursing/technician personnel

in the room during the emergency procedures

The “on-call” personnel may need to stay late in the laboratory for a prolonged or delayed scheduled case orhave to return to the catheterization laboratory in the case

of an emergency at any time, twenty-four hours a day andseven days a week The on-call nurses/technicians arecompensated financially for their time on call In addition,they receive overtime salaries when actually called intothe laboratory In spite of this compensation, the on-callstatus requires a definite sacrifice for the personnel Theymust have a commitment to either no other activities

when on call or being able to interrupt any activity at any time when called With a fully cross-trained staff of

nurses/technicians, this allows the rotation of individualswithin the “on-call teams” and allows some distribution

of the call to suit the schedules of each of the individualsworking in the catheterization laboratory

The extra on-call duty is not the only sacrifice a pediatric catheterization laboratory nurse/technicianmakes In a dedicated, busy, pediatric/congenital cardiac

catheterization laboratory, a “normal”, scheduled day does

not exist Cases frequently extend beyond their scheduledduration as well as beyond the normal working day Theindividual cases frequently are longer than scheduled, thepediatric patients often need stabilization by the catheter-izing physician between the catheterization procedures,which delays the start of the next case, and there are fre-quent “add on”, urgent cases which appear regularly inthe busy pediatric cardiovascular service All of these factors very regularly extend the hours of the pediatric/congenital catheterization laboratory beyond the “8-hourday”

Rare or occasional extra time added to the regular workday is satisfactorily solved by merely having the involvedpersonnel remain beyond the hours of their work day

while receiving overtime compensation in the form of

extra overtime salary or compensatory time off However,

in a busy pediatric/congenital catheterization laboratory

where the extra hours are a regular occurrence, having

each employee working extra hours regularly is not a

solu-tion The cost of regular, repeated overtime pay becomes

prohibitive to the hospital and there is never time

avail-able for the individuals to have compensatory time off

Of even greater importance, the strain on the employees of

never having a fixed or dependable finish time to the

working day results in employee dissatisfaction and a high

employee turn-over Besides the inconvenience of hiring

and retraining new nurses/technicians, the retraining of

new personnel is very expensive and time consuming

As a consequence, in a busy pediatric/congenital

cathe-terization laboratory it is necessary to provide a flexible

working schedule for the nurses and technicians There

must be a sufficient total number of nurses/technicians

to allow for staggered working hours and to allow

addi-tional scheduled time (or days) off to compensate for

hours worked overtime When the catheterization

labor-atories do finish the scheduled cases early, the personnel

are allowed to leave without penalty In a busy laboratory

they still will work their minimal hours! The physicians

working in the laboratory must also use some

considera-tion when adding extra or “urgent” cases which could

possibly be worked into the regular schedule

The multiple duties of the nurses/technicians in a

pediatric/congenital cardiac catheterization laboratory

are divided into three or four different “job descriptions”

during the catheterization:

Recording nurse/technician

One or two nurses or technicians operate the monitor/

recording and the X-ray equipment in the control room

(or area) of the catheterization room The recording nurse

or technician enters the time of the patient’s entry into the

laboratory, all of the patient’s demographics, and the

patient’s vital signs and overall status upon arrival in

the laboratory into the data system of the catheterization

laboratory In the integrated laboratory these data are

distributed electronically to the physiologic recorder, the

data recorder and the X-ray system, otherwise they must

be entered into each of these systems separately When the

data have been entered, the nurse/technician begins a

running, timed and detailed record of every event during

the catheterization procedure These detailed records

docu-ment every event of the procedure with enough detail to

become the critical information for a defense in a court

of law!

The recording nurse/technician “balances” the pressure

transducers electronically and numbers and identifies

each recording At the request of the operating physician

the recording nurse/technician sets the scale or “gain” ofeach of the pressure tracings or changes the gain of all,

or individual, channels When requested, the recordingnurse/technician creates a paper recording of the pres-sure tracings and events occurring on the monitor screen.Most current physiologic recorders also time the eventsand recordings automatically in the computer record and

on any paper recordings The recording nurse/technicianstarts the paper recorder at the onset of a major or unusualevent occurring to the patient in the catheterization labor-atory A well trained, experienced and attentive recordingnurse/technician will begin this recording automatically,without specific instructions and before joining in anyemergency efforts

The data recording person places notations or

com-ments on the timed record in the computer record of any

changes in the patient’s status and for all events occurringduring catheterization The values of the saturationsobtained from the oximeter in the laboratory are enteredinto the running, timed record In most laboratories thesedata are transmitted verbally from the nurse/technician

in the actual catheterization room to the recordingnurse/technician in the control room, who then enters thenumbers manually into the computerized, timed record.The timed record also includes all medications and thedose and route of their administration The introduction,exchanges, and specific manipulations of catheters, wires,sheath/dilators and special devices are all recorded.These recorded data include the type, size, and entry vessel through which the item is introduced

The recording nurse or technician keeps the operatingphysician in the catheterization room constantly apprised

of the patient’s hemodynamic status during the ure The recording nurse/technician keeps track of, andrecords changes in pressures and the electrocardiogramthroughout the entire case and watches particularly for

proced-any significant changes or trends in the patient’s vital signs.

Although the catheterizing physician can see the logic tracings on the monitors in the catheterization room,

physio-he or sphysio-he usually is concentrating on tphysio-he catphysio-heter lations directly on the table or on the fluoroscopic screenand cannot watch the physiologic tracings constantly.When angiograms are obtained, the time, the site of the injection, the type and the amount of contrast, thepressure and rate of injection and the angles of the X-raytubes are recorded on the continuous flow sheet In theelectronically integrated laboratory the X-ray settings areautomatically inserted into the timed record of events,otherwise these values are inserted manually In addition

manipu-to recording all of the angiographic related information,

a nurse/technician in the control room also adjusts themajor settings for exposure rate on the X-ray equipment,the settings for amount of contrast, pressure of injection,flow rate and delay or “rise” time on the injector, “arms”

the injector and then initiates the injection during the

angiogram In some laboratories the nurse/technician in

the control area also operates the start–stop of the

angio-graphic equipment

At the conclusion of the procedure, the time the

vari-ous catheter lines are removed, the time hemostasis is

achieved, the type of pressure bandages applied, the vital

signs and overall status of the patient, the time the patient

leaves the catheterization laboratory and who is

accom-panying the patient out of the room, are all recorded

After the patient is removed from the catheterization

room, the control room nurse/technician makes printed

copies of the catheterization laboratory recorded data for

the patient’s chart and for a hard copy “catheterization

folder” for each patient When the catheterizing

physi-cians have finished all measurements of the images on a

digital system, the images are transferred onto the central

storage computer for archiving and a copy onto a back-up

storage system is performed by the control-room personnel

Whenever possible it is desirable, if not absolutely

necessary, to have at least two recording/operating

nurses/technicians in the control area During a

com-plicated, difficult case and even with many pre-entered

abbreviations and “pentered comments” in the

re-corded data of the catheterization laboratory computer

program, the responsibilities in the control room exceed

the capabilities of a single person

Circulating nurse/technician

The third essential person in the catheterization

labor-atory is the circulating nurse/technician, who performs

his/her activities predominantly within the

catheteriza-tion room This nurse/technician, along with the

“mani-fold nurse/technician”, sets up the catheterization room

for the particular patient This includes opening and

arranging the sterile “catheterization pack”, which

in-cludes the table drape, sterile protective drapes for

adja-cent equipment, towels, “operating gowns”, flush bowls,

specific monitoring lines, and, for each particular patient,

the needles, wires, and introducers Any other special or

particular catheters or other consumable items specified

by the catheterizing physician are added to the tray by the

circulating nurse/technician The circulating

nurse/tech-nician sets up any other special or unique equipment

necessary for the particular patient including the

patient-warming system, intravenous perfusion pumps, cardiac

output computers, etc The circulating nurse/technician

may assist the manifold nurse/technician in setting up the

manifold and in his/her duties when the manifold person

is tied up with other duties

When the patient arrives in the catheterization room,

the circulating nurse/technician helps to position the

patient on the catheterization table and secures them in a

comfortable position with tape or straps This same nurse/technician connects the ECG leads, the pulse oximeter,and a cuff blood pressure cuff to the monitor If the patientrequires a Foley™ urinary catheter, this is inserted at thistime by the circulating nurse/technician When there is anintravenous (IV) line, the fluid connection to the line issecured If there is no IV line and the procedure is beingperformed under deep sedation without an anesthesio-logist, the circulating nurse usually starts a separate IVline once the patient is secure on the table In such a cir-cumstance, if the patient requires additional sedation, thecirculating nurse administers it, either through the IV line

or, when no IV is available, intramuscularly

After the physician has infiltrated each potential vesselentry area with local anesthesia, each area is “scrubbed”thoroughly and widely by the circulating nurse/techni-cian The circulating nurse assists the physician in drapingthe patient to isolate all of the sterile fields with the drapeand in draping all adjacent equipment which might come

in contact with the operator or catheters and wires

Once the catheterization procedure begins, the ing nurse/technician takes the syringes with the bloodsamples for oxygen saturation determination from thephysician, verbally notifies the recording nurse/techni-cian in the control room of the location where the bloodsample was obtained, injects the blood sample into anoximeter cuvette, places the cuvette in the oximeterdevice, reads the digital read-out to the physician/oper-ator and to the recording nurse/technician, and makes arecord of the result from the oximeter The results fromthe oximeter are transmitted verbally to the operatingphysician and the recording nurse/technician in most laboratories

circulat-There now is the capability of the digital read-out from

an A-Vox™ oximeter to be transmitted electronically to aseparate computer for a large display and a site-specific,timed, permanent record This “communication” betweenthe oximeter and the computer requires a special soft-ware program from Scientific Software Inc™ (ScientificSoftware Solutions, Charlottesville, VA) The site wherethe sample was obtained is selected in the program ineither the oximeter or the computer directly by the circu-lating nurse/technician while the time of the reading and the oxygen saturation of the sample are recorded anddisplayed automatically on a computer screen A timed,accurate record of the oxygen saturations and theirspecific sites from the entire catheterization can be printed

at the end of the procedure Eventually, with a smallamount of additional effort on the part of the major manu-facturers, these data should go directly to the recordingcomputer in the control room without the current verbal/manual transmission!

In addition to running the oximeter samples, the lating nurse/technician runs the blood gas analysis or

circu-ACT tests on samples received from the physicians and

assures that the operating physician, the anesthesiologist

and the recording nurse/technician have the results of

these tests The same circulating nurse/technician is

responsible for retrieving additional catheters, wires and

devices as needed during procedure from the “in-room”

or adjacent room storage The circulating

nurse/techni-cian also has the responsibility for periodically loosening

the restraints on the patient’s arms and “exercising” the

arms by putting them through a full range of motion

to prevent brachial plexus injury If the catheterization

laboratory does not have a separate “runner” to retrieve

supplies, blood, etc., from sites remote from the

catheter-ization laboratory, the circulating nurse/technician

per-forms that function

This nurse/technician checks the crash cart for its stock

of expendable supplies and drugs before the procedure

begins and the defibrillator is pre-set according to the

patient’s weight and then checked for function The

circu-lating nurse/technician may be called on to introduce

a nasogastric tube or a nasopharyngeal airway into the

patient electively during the procedure During the

pro-cedure, in the event of an emergency, the circulating

nurse/technician is responsible for bringing the

defibrill-ator to the bedside, “arming” the defibrilldefibrill-ator and giving

the paddles to the physician The nurse/technician,

however, should be capable of confidently applying the

paddles and administering the current him/herself

At the end of the procedure, the circulating

nurse/tech-nician assists the physicians in removing the table drapes

and then applies the pressure dressings to the various

puncture sites after hemostasis has been achieved In a

laboratory still using cine film, the circulator removes the

film cassettes and makes sure the film gets to the person

responsible for processing

“Manifold nurse/technician”

The fourth essential person in the catheterization room

is the “manifold nurse/technician” As the name implies,

the manifold nurse/technician controls the “manifold”a

i.e the stopcocks, transducers and flushing of the

pres-sure/flush lines connected to the patient The manifold

nurse/technician prepares and sets up the plastic

pres-sure bags of flush solution, sets up and balances the

pressure transducers on the manifold, and connects the

pressure bags/flush system to the “manifolds” The

pres-sure transducers are mounted on a stand attached to the

side of the catheterization table, which is adjustable

vertically to allow for the “mid-heart” position according

to the patient’s size The manifold nurse/technician

phys-ically measures the patient’s anterior–posterior chest

diameter with a ruler/caliper and then adjusts the height

of the transducer stand so that the transducers are exactly

at the level of the mid chest The exact site of the

“mid-heart” height can be determined by a brief look atthe lateral fluoroscopy while measuring the chest with

a ruler The accuracy of all of the subsequent pressure

measurements during the catheterization is dependent

on this height measurement and the positioning of themanifolds/transducers!

The pressure bags of flush solution are “spiked” withthe bags upside down so that the vent/connecting tubesare positioned upward Once spiked through the vent/

connecting tubes, the bags are squeezed until every last bitof air is evacuated from the bag as well as out of the

“spiking” tube Once the bag and tubing are emptied pletely of air, three units of Heparin/cc of flush solution

com-are injected into the injection port of the bag and mixedwith the flush solution Once the Heparin is added, thepressure/flush bag is turned right side up with the ventsand tubing now at the bottom of the bag The bag is

rechecked for any residual air in it When the pressure bag

containing the flush fluid unequivocally is empty of air,the bag of fluid is inserted into a pressure cuff, pressure is

applied to the cuff and the tubing is flushed of any ing air Once this bag and tubing system are emptied com- pletely of all air, there is no possible way for air to enter that

remain-part of the system even when the fluid bag is squeezedtotally empty or turned upside down again! The pressurebags are maintained with enough pressure to flush any orall parts of the manifold system and against any intravas-cular pressures (including systemic arterial pressures)with a good, steady flow of fluid

Once the pressure flush lines are cleared, they areattached to the manifolds and the entire system includingthe manifolds, the stopcocks on the manifolds and thetransducers are flushed while “tapping” each plastic joint/connection sufficiently to dislodge any micro bubbles,which invariably are trapped on the poorly “wettable”plastics This assures that the system is completely free ofeven micro air bubbles and that quality pressure curvesare obtained through this part of the system

Once the patient is prepped and draped, the manifoldnurse/technician takes one end of each sterile pres-sure/flush line from the physician and attaches it to themanifold of the appropriate pressure transducer Eachline is placed on a pressure flush to the table while thephysician “taps” that end of the line and the in-line stop-cock until it is free of air and any “micro cavitation” Eachpressure curve displayed on the physiologic monitor iscolor-coded to match a specific transducer Each pres-sure/flush line on the table is also color-coded and isattached to the transducer with the corresponding coloredpressure tracings on the screen The colors on the monitorscreen can be switched or changed completely in therecording computer so that the colors of the flush tubingattached to the transducer and the monitor tracing always

correspond This synchronization of the colors between

the flush/pressure tubing and the monitor tracings easily

and precisely identifies each pressure/flush line with a

specific pressure transducer and tracing on the monitor,

and greatly simplifies and increases the accuracy of the

communication between the operating physician, the

manifold nurse/technician, and the recording technician

when requesting flushing, balancing or changing “gains”

of any particular pressure curve

The manifold nurse/technician flushes and “zeros”

strain gauges at the beginning and as necessary during

the procedure During the catheterization procedure, the

manifold nurse/technician turns the pressures lines on

and off at the manifold and flushes the system and the

catheters from the manifold as directed by the

catheteriz-ing physician The catheterizcatheteriz-ing physician draws blood

samples from a stopcock close to the catheter/line in the

patient and, when sure that there is no air in the system,

returns the stopcock to the flush/pressure position and

requests the manifold nurse/technician to flush the line

The manifold nurse/technician should anticipate and be

ready for the physician’s next move or request whenever a

sample is drawn or a line is disconnected For example,

when a catheter is disconnected from the pressure line in

order to withdraw a blood sample, it always will need

flushing when the line is reconnected to the catheter At

the same time it cannot be flushed until the physician is

sure it is clear of air or clot As the line is being reattached to

the flush system, the manifold nurse/technician should

have his/her hand on the flush stopcock/device awaiting

the request for a flush The physician should never have to

request the flush a second time!

The manifold nurse/technician is trained to recognize

poor and artifactual pressure curves and should be aware

of what causes particular abnormalities in the curves Any

abnormalities noted in the pressure curves should be

pointed out to the catheterizing physician if he/she has

not noticed the problem The most common problems

with the pressure curves are a result of “micro-cavitation”

in the fluid with the creation of micro bubbles as the fluid

warms The almost “non-wettable” nature of the plastics

in the manifold, transducers, stopcocks and tubing allows

for the progressive accumulation of these micro bubbles

until they create an artifactual “over shoot” in the tracing

These artifacts in the pressure curves are eliminated by the

meticulous “tapping” and flushing of all of the plastic

areas of the tubing and connectors as the system is flushed

with the stopcock open and away from the patient

The other major responsibility of the manifold nurse/

technician is the administration of intravenous drugs and

solutions during the procedure, particularly when it is

performed under sedation without an anesthesiologist

Supplemental sedation is the most frequent medication

administered At the time of very critical maneuvers,

often the manifold nurse/technician will have the specificamount of the additional sedation for the particularpatient drawn into a syringe in advance and will alreadyhave the syringe attached to the manifold in anticipation

of the necessary dose In that situation, the additionalsedation can be administered within seconds of when it isneeded and requested The manifold nurse/technicianalso administers other medications/solutions through the catheters, including supplemental narcotics, heparin,electrolyte and glucose solutions and supplemental fluids

as ordered by the operating physician

The manifold nurse/technician also assists the ing nurse/technician in setting up the catheterization laboratory and securing the patient on the catheterizationtable The manifold nurse/technician may assist the cir-culating nurse/technician in his/her duties during the procedure; however, the manifold nurse’s/technician’sprimary responsibility is the manifold and he/she shouldnot be away from the manifold for any significant length

circulat-of time

Extra “float nurse /technician”

During a very complicated case in the catheterization oratory, particularly when multiple samples are obtained

lab-or where many different wires, catheters and devices areused, a minimum of three nurses/technicians is notsufficient to keep up with the pace of the case, much lessoperate the room efficiently This is even truer when acomplex therapeutic intervention is performed When

a complicated case is anticipated, the full complement

of four nurses/technicians is assigned to the room Thefourth person helps with retrieving the multiple pieces ofconsumable equipment, may perform the blood satura-tion, blood gas or ACT determinations, and assists withthe data recording in the control room During a very longcase, the “extra” nurse/technician trades duties tem-porarily with one, or more, of the other personnel in theroom to allow them a transient break The time saved

by utilizing this fourth person easily justifies the tional salary

addi-In cardiac catheterization laboratories which still usecine film, the nurse/technician in the “float position” frequently is the person responsible for processing thecine film In a cine film laboratory either this person, the technical director or the biomedical engineer turns

on the film processor each morning Turning on the cessor includes running a quality control, test filmstripthrough the processor at the start of each day

pro-At the end of each procedure the cine film cassettes are collected from the cine cameras in the catheterizationlaboratory In the processing room of the catheterizationlaboratory, the film is threaded from the cassettes into thephotographic film processor and the processor started

After the film is processed, it is transferred by the nurse/

technician from the processing reels to spools for viewing

on cine viewing machines

Technical director

One nurse/technician of the “catheterization team”

func-tions as the technical leader/director of the

catheteriza-tion laboratories The technical director is responsible for

maintaining the inventory of consumable items,

arrang-ing for the preventive and emergency maintenance of all

of the equipment, and the scheduling of all of the

catheter-ization laboratory personnel With one laboratory, the

time commitment for the technical director for just these

administrative obligations is approximately half of the

working time of one of the other catheterization

labor-atory nurses/technicians With two or more

catheteriza-tion laboratories, the technical director’s posicatheteriza-tion is a full

time job and represents an additional full-time employee

equivalent (FTEE) for the catheterization laboratories

In addition to the technical director, one

nurse/techni-cian is designated as the leader in each room, at least

dur-ing each case The “room” leader for the particular case is

responsible for assigning the specific duties to each of the

personnel in the room during the case and supervising

their activities during the particular case, in addition to

his/her assigned duties

Catheterization laboratory support personnel

Each catheterization laboratory is dependent upon

considerable additional support outside of the actual

catheterization room This includes a nurse for admitting

and preparing the patient for the catheterization,

admin-istrative/secretarial support, environmental services/

custodial support, biomedical support and “out of lab”

engineering support

Admitting / holding area nurse/technician

The primary responsibility of the catheterization holding

area nurse is to facilitate getting the patient safely into

the catheterization laboratory in the most timely manner

possible so that there is no delay in the function of the

catheterization laboratory Most cardiac catheterization

procedures are performed as an outpatient or “day case”,

followed by an extended period of close observation The

patients are admitted directly to an admissions/holding

area in the cardiac catheterization suite where the patient’s

demographics and eligibility are verified, the

adminis-trative admission to the catheterization laboratory is

performed, and the patient is prepared for catheterization

The catheterization admissions area may be exclusively

for admissions to the cardiac catheterization laboratory,

but it is often shared with admissions for the cardiac operating rooms When sharing is possible, considerableduplication of equipment and personnel can be avoided.The admission procedure is relatively extensive Thisincludes administratively documenting the patient’s pre-admission eligibility for the procedure, assigning or veri-fying the patient’s medical record number, placing thepatient’s identity bracelets on them, and the preparationand organization of the patient’s chart Medically, the pre-admission history and physical examination are verified

or obtained, the previous laboratory work is checked forits results and its completeness, and samples for any nec-essary additional laboratory work are obtained When theuse of blood during the procedure is considered a possi-bility, a blood sample is obtained for type and cross match

or the availability of blood from a previous cross match isverified Finally, it is assured that the procedure is under-stood by the patient/their family and that the “operatingpermit” is understood and signed by the appropriate person(s)

Even patients already admitted to the hospital, butcoming from other areas of the hospital, are “admitted” tothe catheterization laboratory through the catheterizationlaboratory admitting/holding area This assures that thepatients are completely ready for the procedure bothphysically and mentally and that they are physically inclose proximity to the catheterization laboratory as soon

as the catheterization room is ready for them Having the patients prepared by the catheterization laboratorypersonnel and close to the laboratory facilitates a rapid

“turn around” time in the catheterization room betweenpatients

The patient is dressed in a hospital gown and is aged to void before being placed on a stretcher/bed Thepotential introduction sites for catheters are scrubbed(and shaved if necessary), a peripheral intravenous line isstarted and the patient is given their pre-medication at theappropriate time If the patient is to receive general anes-thesia, the anesthesiologist is informed of the patient’spresence and consults with the patient and family if theyhave not seen them earlier

encour-A nurse who is very familiar with the catheterizationprocedures performs the admission procedures and thepreparations of the patient This nurse is usually one of thecatheterization laboratory nurses/technicians or, at least,

is assigned to the catheterization laboratory and is ible to the catheterization laboratory The “holding area”

respons-nurse is responsible for the efficient and timely movement

of the patients to the catheterization laboratory The tics of moving several patients through the holding areawhen there are two or more catheterization rooms withboth rooms starting at the same time requires some assist-ance, temporarily, from one or more of the “in-room”nurses/technicians

logis-Ideally the patient is ready to enter the catheterization

room as soon as it is ready for the patient The

hold-ing area nurse/technician keeps the physicians in the

catheterization room notified of the status of the patients

in the holding area, keeps the patient/family informed of

their potential starting time and, in doing so, helps to

explain any delays from the originally scheduled time

When there are significant delays, the holding area nurse

can arrange for a change in the patient’s “nothing by

mouth” status

Administrative/secretarial support

In addition to the nursing/technician staff actually

oper-ating the catheterization rooms, each catheterization room

requires significant administrative and secretarial support

The extended schedule of the catheterization

labor-atory, the daily schedule of the patients, the schedules

and the assignments for each of the laboratory personnel

within each room as well as the schedules for the time off,

holidays and “on call” for each of the personnel, all have

to be created, maintained and “published” The time

sheets for each of the personnel are maintained on a daily

basis Purchase orders for all of the consumable materials

are completed and submitted expeditiously As all

con-sumable items are received, the original orders are

compared with the items received and verified The

catheterization laboratory director is informed of any

delays/discrepancies in the orders received The

adminis-trative secretary prepares the billing sheet for the

pro-cedure, which includes each procedure performed and

each piece of consumable equipment that is used in the

catheterization laboratory during a procedure This is

submitted to the hospital billing office for the hospital

charges

A new cardiac catheterization record and folder are

cre-ated for each patient, and for each time they undergo a

procedure in the catheterization laboratory This patient

catheterization laboratory folder contains copies of the

pressure tracings, a printout and tabulation of all of the

hemodynamic data from the procedure, the diagram(s)

of the particular heart, a descriptive summary of the

important maneuvers and procedures performed during

the catheterization procedure, a description of the

angio-graphic technique during each angiogram along with a

description of the findings from the angiograms, and

a summary of the diagnoses and recommendations as

a result of the procedure Ideally, the catheterization

summaries are transcribed by a transcriptionist, who is

assigned to the catheterization area and who, in turn,

understands the terminology and information in the

sum-maries When the transcriptionist is a member of the

catheterization team, any questions about, or peculiarities

of the catheterization summary can be clarified directly

and in a timely manner by the physicians or personnel inthe catheterization laboratory The more detailed andspecific the catheterization report, the more necessary isthis close working association In laboratories where thecomplex anatomy is transferred to an individualized dia-gram, this close cooperation is even more essential Copies

of the finalized catheterization report are included in thepatient’s hospital record and sent to the referring physi-cians by the catheterization laboratory secretary

The catheterization folders are stored in, or in the diate area of, the catheterization laboratory, separate fromthe central hospital records, and are maintained by thecatheterization laboratory administrative personnel Thecatheterization records must be available for rapidretrieval whenever old information on the particularpatient becomes necessary for subsequent catheteriza-tions in the future As many of the most recent catheteriza-tion records as possible are stored in the immediatecatheterization laboratory area and the remaining (themajority) of the folders must be stored in “off-site” stor-age When it is possible to reproduce a hard copy conveni-

imme-ently and reliably from an entirely electronic record, the

catheterization records are maintained entirely in a puter storage system with a separate electronic backup

com-In addition to the hemodynamic data, all angiogramsare cataloged with permanent copies stored so they can

be retrieved easily and expeditiously This requires amonumental amount of organization and filing space.With a completely digital laboratory, a digital copy of theangiogram is stored on readily accessible, large “Raid”disks in the cardiac catheterization laboratory/hospitalcomputer system A separate hard copy of the digitalangiogram is maintained as a separate archive This separate archive copy is stored on either a digital tape, anoptical disk or separate compact disks In any case, thesecopies are cataloged and physically stored so that they can be retrieved readily or copied back into the electronicsystem

Cardiac catheterization laboratories which still use cineangiography have the additional logistical and spaceproblems of a cine-angiogram storage system which isuseable yet conserves as much space as possible Large

“rolling files” of the cataloged cine films, which are tained by the administrative personnel of the catheteriza-tion laboratory, are very efficient, but at the same timeoccupy large amounts of space in the catheterization area

main-Biomedical support

The “in-house” biomedical engineer(s) for the ization laboratories is/are committed full time to thecatheterization laboratories or, at least, they have theirtime prioritized for the catheterization laboratories Thecomplexity of the equipment in the modern cardiac

catheter-catheterization laboratory no longer allows for the

labora-tory to be dependent only on outside or manufacturers’

engineers for the minute-to-minute support of the

cath-eterization laboratory Each minute of down time in an

operating catheterization laboratory adds up to hours of

extra, uncompensated expense to the hospital The

in-house biomedical engineers must be intimately familiar

with all of the catheterization laboratory equipment,

capable of repairing most of the electrical/mechanical

equipment, and at least “resetting” major X-ray computer

“lock-ups” The in-house biomedical personnel should be

able to change common “boards” on the X-ray equipment

and of equal, or more, importance, expediently identify

major problems with the equipment which do require out

of hospital manufacturers’ support

The in-house biomedical engineers must also have a

good working relationship with the engineers from the

manufacturers/distributors of all of the catheterization

laboratory equipment in order to have good “out of

hos-pital” and in-depth support No in-house biomedical

per-sonnel are expected to be experts in each of the infinite

types or the continual upgrades of the varieties of capital

equipment in a catheterization laboratory Similarly, no

catheterization laboratory, no matter how large or how

many catheterization rooms, can maintain a complete

inventory of spare parts for all of the electronic, X-ray and

mechanical equipment in the laboratory

The catheterization laboratory equipment usually is

extremely dependable; however, when it does fail, rapid

quality service is indispensable When service cannot be

accomplished expediently by the in-house engineers,

manufacturers’ support that is immediately available

and reliable is essential for the repair of malfunctioning

equipment or replacement of defective equipment in the

catheterization laboratory A busy cardiac catheterization

laboratory relies upon the manufacturers’ local

represent-atives to maintain an inventory of repair/replacement

parts within a reasonable access to each laboratory The

availability of this manufacturers’ support should play an

essential part in the decision as to which type of

equip-ment to purchase

In 2005, no piece of equipment, no matter how large or

where it is manufactured, is more than 24 hours away

from a major city! Entire catheterization laboratories

rou-tinely are shipped around the world and assembled within

a day for a sales display! The care of patients should receive

at least as much priority as a sales exhibit!

A “down” catheterization laboratory is not just an idle

piece of “real estate” Inoperable equipment interferes

with the timeliness of the remainder of the medical

ther-apy for the particular patientafor example the cancelation

of surgery which is already scheduled for that patient

following the catheterization In addition to the huge

inconvenience and disappointment, the patient or their

family incur extra expenses for their travel, the associatedcosts for lodging and feeding the remainder of the family,the lost work time for the “provider” or lost school timefor the patient plus the additional hospital expenses of anextra stay

A “down” catheterization laboratory also incurssignificant ongoing expense for the hospital while the lab-oratory is out of function The personnel on the catheter-ization laboratory staff still receive a salary, but are idle.There is a necessary rescheduling of any other patients inthe catheterization laboratory (and possibly in the operat-ing rooms and other hospital schedules to accommodatethe canceled patient(s)) The physicians involved are notoptimally productive and require urgent rescheduling oftheir own, as do many other persons’/patients’ activities

Housekeeping /environmental services

A cardiac catheterization laboratory is considered a sterileenvironment like an operating room In order to maintainthis environment, the walls of the room and each piece ofequipment in the room require frequent scrubbing or wip-ing down to prevent dust from accumulating The entirefloor requires a thorough antiseptic mop scrub at least once

a day as well as localized scrubbing between each case

In order for a catheterization laboratory to have a rapidturn around for multiple patients during the day, thecatheterization room must have a very rapid but thoroughcleaning between cases This includes scrubbing down thecatheterization table with a disinfectant and actuallyscrubbing the floor of the room with a mop All biologic-ally contaminated materials must be gathered and dis-posed of properly in “bio-hazard” containers before a new patient can be brought into the room Usually thesecustodial services are performed by individuals from an

“environmental services” department When the mental services personnel are not part of the catheteriza-tion laboratory team, but are assigned from other areas ofthe hospital to help occasionally in the catheterization lab-oratory, there is frequently a significant delay in gettingthem back to the catheterization area at the critical times.The nurses/technicians can (and often do) perform the between-case cleaning However, these same nurses/technicians have numerous other absolutely necessaryduties at the end of one case and just before the next case,but that incurs an obligatory delay while the nurses/technicians perform the extra custodial duties instead oftheir nursing duties A catheterization laboratory servicewith two or more active laboratories justifies a separateemployee from environmental services who is assigned

environ-to the catheterization laboraenviron-tories The environmental services person then becomes very familiar with the oper-ation of the laboratories, is always available in the laborat-ory area and, as a consequence, is able to anticipate the

end of cases and facilitate the cleanup between cases The

employee from environmental services who is assigned to

the catheterization area and becomes part of the

function-ing team also takes more pride in their individual area and

tends to perform better

Catheterization laboratory nurse clinician

Although often not included as part of the catheterization

laboratory support personnel provided by the hospital,

one, or more, nurse clinician(s) working with the

physi-cian(s) is/are an indispensable part of a catheterization

laboratory team The nurse clinician provides continuous

contact/communication with the family or patient before,

during and after the catheterization This ongoing

com-munication is invaluable in maintaining a solid rapport

with the patient and their family

The nurse clinician answers questions pertaining to

the catheterization and checks on the patients when the

physician is occupied in the catheterization laboratory or

elsewhere and is not available The nurse clinician can

arrange for and schedule the necessary laboratory work

pre- and post-catheterization The nurse clinician actually

performs the patient scheduling for the catheterization

laboratory and coordinates support from anesthesia,

echocardiography, respiratory therapy and other cialty services The nurse clinician prepares the patient fordischarge and arranges for their follow-up care followingthe catheterization When the patients are on “protocol”studies with follow-up visits required at specific timesand with specific tests, the nurse clinician arranges theseand assures compliance with the protocol All of these

spe-activities could be performed by the cardiologist; however,

the catheterizing physician is far more productive as apatient care provider and for “income generation” whileactually performing catheterizations

References

1 ACC/AHA A.C.o.C.A.H.A.A.H.T.F.o.C.C ACC/AHA lines for cardiac catheterization and cardiac catheterization

guide-laboratories J Am Coll Cardiol 1991; 18: 1149–1182.

2 Allen HD et al Pediatric therapeutic cardiac catheterization:

a statement for healthcare professionals from the Council

on Cardiovascular Disease in the Young American Heart

Association Circulation 1998; 97(6): 609–625.

3 Dehmer GJ et al Lessons learned from the review of cardiac

catheterization laboratories: A report from the laboratory vey committee of the Society for Cardiac Angiography and

sur-Interventions Cathet Cardiovasc Intervent 1999; 46: 24–31.

Precatheterization preparation of

the patient

The preparation of the patient for a cardiac catheterization

is an individualized process for each patient and each

cardiac catheterization laboratory There are no hard and

fast rules, but there are volumes written on the subject3

Patient preparation begins as soon as the decision is made

to perform the procedure All patients beyond infancy,

including young children and regardless of the type of

sedation or anesthesia which is used, do need, at the very

least, a general explanation about the procedure and the

reason why the procedure is being performed This should

include at least a description of the portions of the

proce-dure of which the patients themselves will be aware There

are very few things which can make a child or older patient

more anxious, more distrusting or more uncooperative

during a cardiac catheterization, than for them to be told

ahead of time that “nothing will hurt” For a child

under-going a catheterization, there is nothing worse than for the

child to believe that nothing more than a routine “office

visit” is going to occur when they arrive at the hospital!

The exact details provided to the patient, of course,

depend upon the age, understanding and “interest” of the

patient and must be “tailored” according to the response

of the patient during the explanation The information

given to the young patient must be truthful, although not

necessarily in enough detail to induce even more anxiety.

The discussion should include information about the

necessary pre-procedure laboratory studies including the

inevitable “needle stick” for the blood work and

premed-ications/intravenous lines and, for younger children,

mention of the transient separation from their parentsa

emphasizing the transient! Older children, adolescents

and adult patients are also informed about the length of

the procedure, the expected stay in the recovery area, any

peculiarities of the recovery (IV lines, bladder catheters,

etc.) and the length of the expected total stay in the

pital The patient is made familiar with the general

hos-pital environment, the catheterization laboratory itself,

and the post-catheterization recovery area

Older patients and the patients’ families need a more

detailed explanation of the catheterization procedure

This greater detail still is “tailored” to the particular

cap-abilities and understanding of the patient and family

Parents or patients who are in a decision-making position

are informed in detail of the risks of the procedure

However, unless the patient is at an unusually high risk

(e.g very high pulmonary vascular resistance), the

empha-sis of the discussion about the catheterization should be

about the reason for the catheterization, the technical

aspects of the catheterization within the understanding of

the patient/family and not just about the risks Although

providing the full details of all of the potential risks of theprocedure may make the operator feel “medico-legally”more comfortable, such discussions only increase the

patient’s/family’s anxieties further and do not help in a

court of law

No infants, and almost no children, need sedation ormedications to “relax them” on the day, or even the nightbefore, the procedure On the other hand, the adolescent,

the adult congenital patient and, occasionally, the parents

of the patient, can often be inordinately apprehensive Inthat circumstance, both the patient and the parent benefit

from a mild sedative given to the parent the night before

the procedure!

In addition to the explanation and psychological ration for the catheterization, there is other information/instruction provided to the patient when the decision ismade to proceed with a cardiac catheterization Their

prepa-“administrative” admission preparations with the pital, with the patient’s insurance carrier or payer arearranged as soon as the need for catheterization is deter-mined Patients who need pre-treatment of any sort aregiven an admission date sometime before the day of thecatheterization However, since most catheterization pro-cedures are “day admission” procedures, the patients

hos-need detailed instructions about where and at what time they

are expected to arrive at the hospital before the procedure.Most cardiac catheterization laboratories have a specificadmitting/holding area for the admission and prepara-tion of patients for catheterization Obviously the timevaries according to when the patient is scheduled for thecatheterization during the day A patient who is “pre-admitted” administratively arrives at least one-and-a-half

to two hours prior to the scheduled procedure There is

no reason to have patients who are scheduled for thecatheterization later in the day arriving early in the morn-ing! This will only aggravate the patients and make themmore apprehensive

Older patients are given instructions on preparation ofthe catheterization site(s) including scrubbing and shav-ing the area(s) themselves When the femoral approach isused, the patient should shave each inguinal area fromside to side, from iliac crest to iliac crest (“hip bone to hipbone”) and from above to below, from the supra pubicarea to just above the knees Particularly “hairy” patientsare instructed to shave around their entire thighs and uponto the lower back above the hips when “pressure” band-ages are to be applied after the procedure

For the very “needle shy” child or adolescent and withknowledgeable parents, EMLA™ cream is prescribed andinstructions are given for the application of the cream at

home to several potential areas for intravenous needle

punctures before the child arrives for the catheterization4

To be effective, the EMLA must be applied one-and-a-half

or, preferably, two hours prior to the needle puncture

Nutritional and fluid requirements

precatheterization

The patient is encouraged to have regular meals and an

increased amount of oral fluids up to 6 hours prior to the

procedure Often, nothing by mouth (NPO) is ordered for

the patient for eight, ten or more hours prior to the onset of

the procedure In actuality, it rarely is necessary and even

can be detrimental to have the patient NPO for more than

six hours before the beginning of the procedure The child

who is ordered “NPO after midnight” and who was put to

bed at 8:00 or 9:00 pm the evening before the procedure,

may well have had nothing by mouth for 12 or more hours

by the time they arrive in the catheterization laboratory

the following morning! If a long period of time is

antici-pated between the patient’s last oral intake and the

begin-ning of the procedure (e.g all night), the patient should be

ordered or given oral, clear liquids within six or seven

hours of the expected start of the procedure This should

be encouraged, even if it means waking the patient during

the night This fluid intake is even more important in very

young, cyanotic or polycythemic patients In these

cir-cumstances, it is preferable to start an intravenous line

and the patient is given intravenous fluids to maintain

their hydration while waiting for the catheterization,

par-ticularly if there is a delay in the start of the catheterization

procedure One-quarter normal saline or Ringer’s lactate

is administered at a maintenance rate according to the

patient’s size

Infants and small children have different

fluid/nutri-tional needs from older patients The emptying time of

their stomach normally is much faster than in an older

child, the emptying time of the stomach is not as affected

by anxiety about the impending procedure, and they

become dehydrated and hypoglycemic faster than an

older patient As a consequence, infants only need to be

restricted from oral feeding for four hours prior to the

pro-cedure, and a specific effort must be made to insure clear

fluids are provided to them just before they are made

“nothing by mouth” This becomes even more important

in chronically ill, cachectic infants Parents are encouraged

to wake the infant during the night within five hours of

the procedure and to feed the patient at least clear liquids

at that time

Immediate precatheterization preparation

If it was not applied at home and it is to be used, EMLA

Cream™ is applied locally over the sites for the possible

intravenous punctures as soon as the patient arrives in the

holding/admitting area EMLA™ cream appears to be

effective at reducing the discomfort from the punctures

for starting peripheral intravenous lines and even for the

percutaneous catheter introductory sites, however, the

EMLA™ cream must be applied at least one, and ably two, hours prior to the skin and vessel puncture to

prefer-be at all effective When the patient has had previouscatheterizations and has any “memory” of the catheterpuncture sites, EMLA™ cream also is spread over thepotential percutaneous sites

In the “holding area” or on a ward, any infant who has more than a four-hour delay before the start of thecatheterization and after being placed nothing by mouth(NPO), should have intravenous fluids running or started

In infants, the intravenous fluid should contain 5% trose in quarter normal saline to prevent hypoglycemia aswell as maintaining the patient’s hydration At the sametime, only an individual who is very skilled at startingintravenous lines should introduce this intravenous line

dex-in dex-infants This is particularly true dex-in small dex-infants orcachectic patients, where it often is very difficult to intro-duce a line into a vein In spite of the multiple advantages

of the indwelling intravenous line, the presence of such a

line never justifies extensive trauma or the exhaustion of

the patient from the crying and fighting created by longed or multiple “sticks” during unsuccessful attempts

pro-at starting an intravenous line

In the extremely anxious or combative child, wherestarting an intravenous line is out of the question, an

intramuscular dose of 1–2 mg/kg of ketamine provides a

very effective and very rapid sedation for the child prior

to starting the intravenous line or catheterization In theworst-case scenario, where an intravenous line cannot bestarted, the entire premedication is given intramuscularly

In infants and small children, intranasal midazolam in adose of 0.25 mg/kg is effective and fairly rapid at produc-ing sedation sufficient for starting the intravenous line Ifproblems are anticipated, or in a very anxious patient,midazolam in a dose of 0.2 to 0.6 mg/kg, administeredorally 30 to 45 minutes prior to starting the intravenouspuncture, is effective in calming the patient enough

to introduce the intravenous line Midazolam, by eitherroute, is not as predictable or as effective as ketamine.Following the administration of either midazolam orketamine, the patient should be observed very closely andplaced on an ECG monitor

In addition to the fluids and intravenous lines, there areseveral additional preparations for the catheterization inthe holding area before the patient enters the catheteriza-tion laboratory Any necessary laboratory work (bloodCBC, chemistries, urinalysis, X-ray, ECG or type and crossmatch), which was not completed previously, is carriedout at this time The patient is dressed in a hospital gownand when old enough to cooperate, asked to empty theirbladder If the start of the catheterization is delayedsignificantly after the patient arrived in the holding area,the patient is asked to empty their bladder again justbefore they are taken to the catheterization laboratory

The patient’s catheterization sites are cleaned If the

catheterization sites were not shaved adequately by the

patient him/her self, the areas are shaved (again) while in

the admitting/holding area The final paper trail leading

to the cardiac catheterization, including the “informed

consent” forms, are completed and verified

Polycythemia/anemia

Patients with significant polycythemia or anemia require

additional preparation for a cardiac catheterization Both

of these problems negate the validity of any

hemody-namic measurements and significantly increase the risk of

all cardiac catheterizations

Polycythemia occurs in cyanotic patients and is

particu-larly common in the older cyanotic patient A patient is

considered polycythemic with a hematocrit over 65%

Problems from the polycythemia increase with the

increasing severity of the condition, particularly when the

hematocrit is over 75% Although polycythemia increases

the oxygen carrying capacity of the particular aliquot of

blood, it decreases the overall cardiac output and the

local-ized blood flow along with oxygen delivery to the tissues,

and significantly increases the risk of thrombosis and

emboli because of the thickened blood Polycythemia is

treated by a phlebotomy, which includes the replacement

of the blood withdrawn with a colloidal fluid The patient

undergoing cardiac catheterization has the phlebotomy

performed in the catheterization laboratory, after the

venous and arterial lines have been introduced, but

before the actual catheterization procedure is performed

The details of a phlebotomy procedure are discussed in

Chapter 34

At the other extreme, anemia decreases the oxygen

carrying capacity of the blood, falsely increases the

cardiac output, and aggravates congestive heart failure

Any measurements of blood flow are falsely elevated

by significant anemia Any pre-existing anemia is always

made worse during a cardiac catheterization by both the

accepted, obligatory blood loss, which occurs during the

required blood sampling for blood oxygen saturation,

clotting studies and blood gas determinations, along with

the additional inadvertent blood loss occurring at

vascu-lar puncture sites, around catheters/wires and during

sheath/catheter exchanges When starting with less than

8–10 gm of hemoglobin in a small patient, none of the

hemodynamic measurements will be valid Of equal or

greater importance, such an infant can easily reach a point

of cardiovascular collapse from the cumulative blood loss

Any significant anemia should be identified and

cor-rected before the catheterization procedure Preferably

in an elective situation, the anemia is diagnosed weeks

before the catheterization and treated with oral iron

sup-plements If the anemia is not recognized until the time

of the catheterization and the catheterization is urgent, the patient’s hemoglobin/hematocrit is corrected in thecatheterization laboratory with a slow transfusion of

10 ml/kg of packed red blood cells and before anycatheter manipulations or hemodynamic measurementsare carried out

Premedication for cardiac catheterization

Some premedication to sedate the patient before thecatheterization is utilized by most pediatric/congenitalcardiac catheterization laboratories The goal of the pre-medication is to have the patient arrive in the catheteriza-tion laboratory calm, sleepy, and cooperative but, at thesame time, not so obtunded that they need to be lifted onto the catheterization table or need ventilator support.The premedication usually is administered to the patient

in the admitting or holding area of the catheterization laboratory or on a hospital ward before the patient entersthe catheterization laboratory Premedication can beadministered orally, intramuscularly, or intravenously,although intravenously is preferred Intravenous medica-tions can be titrated or repeated without disturbing thepatient

Regardless of the route of administration of the initialpremedication, it is desirable to have a secure intravenous(IV) line functioning in the patient prior to receiving thepremedication and certainly before entering the labora-tory for the catheterization procedure If the intravenousline is not in place prior to the patient’s arriving in theholding area for the procedure, it is put in place in the holding area while the patient is being prepared forthe procedure The intravenous line provides a directroute for the administration of the initial premedication,

a route for supplemental medications preceding and ing the procedure and, if necessary, for emergency andresuscitative medications When administering the pre-medication through an intravenous line, the dose of themedication can easily be titrated up or down or supple-mented with additional medications without traumatiz-ing the patient further

dur-When general anesthesia is not used, virtually all

infants, children, adolescents and even adults undergoing

a cardiac catheterization for a congenital heart lesion,require some sedation and systemic in addition to local

analgesia There are a very few patients who are stoical

enough that they do not need, nor desire either sedation orgeneral anesthesia for a short catheterization procedure

All patients undergoing long catheterization procedures

should receive systemic analgesia with sedation and/orgeneral anesthesia Although after the skin puncture the

cardiac catheterization procedure per se usually does not

cause pain, the patient undergoing catheterization is in

an unfamiliar, frightening environment, is required to lie

very still on an uncomfortable “table” and to remain still

for a long period of time During a long procedure,

an indwelling Foley™ catheter is placed in the urinary

bladder in order to prevent the extreme discomfort of a

very full urinary bladder Either the Foley™ catheter itself

or the full bladder will add to the patient’s overall

discom-fort The majority of patients usually are “restrained” on

the catheterization table, which adds further to their

anxi-ety and discomfort

Regardless of the age of the patient, under-sedation

or no sedation results in a patient who is uncomfortable,

anxious, straining, moving, hyperventilating or even

cry-ing throughout the procedure This not only is cruel to the

patient and to the staff of the catheterization laboratory,

but also produces very significant changes in the

physio-logic “steady state” of the patient, which introduce

marked, artifactual variations in any of the measured

hemodynamic parameters When the patient is not in an

absolute steady state, the artifacts make all of the

meas-urements of these parameters totally useless and the

calcu-lations from these measurements totally invalid Adequate

sedation is even more critical in the infant where,

propor-tionately, a huge amount of energy is expended in crying

or straining with a resultant, very significant stress placed

on the myocardium

The premedication is given thirty to sixty minutes prior

to the anticipated onset of the procedure Most

premedi-cations contain a combination of an analgesic and a

sedat-ive Often, an anxiolytic medication is mixed with the

sedative/analgesic for its added “tranquilizing effect” on

the patient Because of the variable response between

individual patients, the markedly different ages of the

patients in a congenital cardiac catheterization laboratory,

and the complexity of the hemodynamics seen in

con-genital heart patients, no single medication, particular

combination of medications, or single dose of medication

is satisfactory for all patients

When any premedication is administered, the operator

or another qualified physician must be available within

close proximity to the area of the patient when the

pre-medication is given This precaution is necessary in the

event of an unexpected adverse reaction by the patient

to the premedication Additionally, any patient who

receives premedication is monitored with, at least, an

ECG, pulse oximetry and frequently recycled, cuff blood

pressure determinations This monitoring begins just

prior to receiving the premedication and is continued

until the patient is attached to the monitoring systems in

the catheterization laboratory The interval of time

imme-diately after the patient has received their premedication

and before the procedure actually starts is the most

vul-nerable time for complications to occur from

premedica-tion in these patients During this time, the patient often

has very little external stimulation and, as a consequence,

experiences a more profound sedative and respiratorydepressive effect from the premedication than during thetime when they are actually in the laboratory during the procedure This same circumstance holds true afterthe procedure is completed when the sedation is still ineffect but, at the same time, all lines are out and all otherexternal stimulation is stopped The patient often lapsesinto a deeper level of sedation when all activity about thepatient has stopped and after a pressure dressing has beenapplied to the puncture site(s) The patient should havecontinual monitoring until they are fully awake and intel-ligibly conversant following the catheterization

In infants and very small children, it is particularlyimportant that blood glucose levels and body temperatureare monitored during any period of sedation Hypo-glycemia develops very rapidly in the small or sick infantwho has had restricted oral intake for any period of time

In addition to being potentially very dangerous to the central nervous system, hypoglycemia initially makes

an infant uncomfortable, irritable and impossible tosedate Unaccounted for irritability in a small infantundergoing catheterization immediately should suggesthypoglycemia

A drop in body temperature of all patients is anticipated

in the cardiac catheterization laboratory The patient hasmost (all!) of their clothing removed and the environment

of the hospital/cardiac catheterization laboratory isalways cool, if not actually cold In the laboratory, thepatient is scrubbed and prepped so that the cold ambientenvironment is aggravated by the moisture and surround-ing wet drapes The core temperature of infants and debil-itated patients in particular, drops precipitously unlessspecific measures are taken to maintain their body tem-perature The hypothermic patient becomes acidotic andvery irritable from the hypothermia alone

General management in the catheterization laboratory

Immediately upon entering the catheterization laboratoryand while being secured on the catheterization table,monitoring of the sedated patient is transferred to themonitoring systems of the catheterization laboratory.Monitoring in the catheterization laboratory includes two,

or preferably three ECG channels, a pulse oximeter with adisplay on the central monitor and, until an indwellingarterial pressure line is available, a frequently recycled,cuff blood pressure determination is displayed on the

monitor In addition, infants are attached to a respiratory

monitor and an esophageal or rectal temperature probe.The esophageal or rectal temperature probe provides acore temperature and is far more secure and reliable than

a skin temperature probe, which can easily be dislodged

from moist skin Even when in place skin temperature

probes do not provide a true or reliable core temperature

because of skin moisture, evaporation and restricted skin

blood flow from vasoconstriction

Even when a patient has “only sedation” or no

seda-tion is anticipated for a catheterizaseda-tion procedure, the

catheterization laboratory must always be prepared for

all hemodynamic and ventilatory emergencies All

cardio-resuscitative, anti-arrhythmic and other supportive

equipment and medications must be available

immedi-ately in the cardiac catheterization laboratory The

equip-ment and expertise for orotracheal or nasotracheal

intubation for any age or size patient must also be

avail-able immediatly in the catheterization laboratory This

includes an entire spectrum of laryngoscope blades,

endo-tracheal tubes, suction equipment and the medications

necessary to perform the intubation including

supple-mental sedation and paralytic agents

Endotracheal intubation and controlled ventilation

implies that the patient is receiving general anesthesia

Although it is convenient to have an anesthesiologist

controlling the airway when the patient is intubated and

ventilated, it is not always necessary unless an inhalation

anesthetic is being used Endotracheal intubation and

controlled ventilation do allow complete control of the

patient’s respiration This is a great advantage in patients

with underlying airway problems or respiratory distress

from congestive heart failure In a catheterization

labora-tory, which is staffed with trained nurses and skilled

pediatric cardiologists, endotracheal intubation can be

performed by the pediatric cardiologist and the control of

the ventilator can be managed by a trained respiratory

therapist when the patient is on room air or oxygen This is

particularly true with infants and smaller children The

respiratory therapist adjusts the ventilator according to

the desires of the primary operator and performs

addi-tional tasks such as the administration of oxygen or nitric

oxide

When a long procedure is anticipated (or even

pos-sible!), a Foley™ bladder catheter is placed in all patients

past infancy During a long case, the patient frequently

receives a large volume of flush solution and, in addition

to the fluid, a large volume of contrast material The

com-bination produces vigorous diuresis and usually a very

large volume of urine The past-infancy patient, may not

be able, or may be unwilling to void spontaneously on

the table and, in turn, develops a markedly distended and

very uncomfortable bladder No amount of sedation/

analgesia, short of very deep general anesthesia, can

over-come this discomfort The Foley™ catheter in the bladder

also allows accurate monitoring of the patient’s urine

output during the procedure, which, in turn, is a rough

reflection of their systemic cardiac output from minute

to minute

Local anesthesia

Once the patient is positioned, secured on the proceduretable and attached to the monitoring and warming systems,

local anesthesia is administered to all sites where catheters

or indwelling monitoring lines will be introduced

or without the use of Emla™ cream at the site, the injection

of the local anesthetic usually arouses the sedated patientfrom their “tranquil”, premedicated state

to sleep, even as the remainder of the local anesthetic isintroduced subcutaneously or the needle punctures forthe catheter introduction are performed Occasionally,supplemental sedation is necessary to complete the localanesthetic infiltration, particularly if there has been adelay between the time when the premedication wasadministered and when the punctures are started for thelocal anesthesia

The local anesthesia will last only 2–3 hours During anycatheterization lasting more than 3 hours, the local anes-thetic, arbitrarily, is re-administered around each sheath/

catheter introduction site Any time a patient arouses

during a cardiac catheterization, the adequacy of the local

anesthesia should be the first thing checked Most of the

time, when a patient awakens during the procedure, it isbecause of pain from the local cutaneous manipulationsoutside of the original area of local anesthesia at the intro-ductory site, or because of pain as the local anesthesiawears off It is much safer and more effective to administer

additional local anesthesia at a skin site which is painful than to try to overcome that pain with systemic analgesia

or sedation

Sedatives, analgesics and anesthesia in the

catheterization laboratory

Most cardiac catheterization procedures are performed

using a controlled deep sedation/analgesia or total,

gen-eral anesthesia The goals of premedication, sedation and

anesthesia before and during a cardiac catheterization are

very similar These medications primarily are intended

to alleviate the patient’s anxiety and to eliminate any

dis-comfort to the patient from the procedure A secondary

goal of these medications is to maintain the patient in a

very still “steady state” and totally “cooperative” during

the procedure The necessity of keeping the patient

per-fectly still at certain stages of the catheterization has

become increasingly important with the implant of

intra-vascular devices At the same time, optimal safety and

the patient’s stable physiologic status must be assured

during all phases of the sedation/anesthesia

General anesthesia is not required or necessary for most

cardiac catheterization procedures At the same time,

there certainly are patients or particular catheterization

procedures where general anesthesia is very desirable, if

not essential Additionally, there is often only a very fine

line between controlled, deep sedation and general

anes-thesia The same medications or combinations of

medica-tions, used in different dosages, may be used for both

controlled, deep sedation and general anesthesia With

the exception of several of the specific intravenous (IV)

anesthetics and the inhaled anesthetics, the major

distinc-tion between sedadistinc-tion and general anesthesia is which

physician is administering the sedation/anesthesia

When the cardiologist who is performing the procedure

administers the medications for the sedation, the

proce-dure is being performed under what is considered

con-trolled, deep sedation In this circumstance the cardiologist

is, unequivocally and totally, responsible for the level of

sedation, the patient’s respiration, the monitoring of all of

the vital signs, and the administration of any medications

during the procedure When the sedation/anesthesia

is administered by the anesthesiologists, it is considered

general anesthesia In addition to administering the

medications, the anesthesiologist assumes control of the

patient’s respirations, the administration of intravenous

medications, and some of the monitoring of the patient’s

vital signs and hemodynamic parameters In spite of this

shift in responsibility for the ventilation and sedation of

the patient, the operating cardiologist is, ultimately, still

responsible for the patient

There are many different regimes utilized for

premedi-cation, sedation and analgesia during the cardiac

catheter-ization of pediatric and congenital heart patients Many of

the sedation regimes utilized during the catheterization

procedure are continuations or repeat doses of the

ori-ginal premedication Most premedication and “sedation

combinations” used in the laboratory include both a ive and an analgesic Often an anxiolytic medication isadded to the sedative and analgesic mixture to maintainthe patient “tranquilized” When a patient “doesn’t care”,often far lower doses of sedatives and analgesics arerequired All of the medications have potential problems

sedat-in any patient, but they are particularly hazardous sedat-inpatients with complex congenital heart lesions It is imper-ative that the physiologic and hemodynamic effects ofeach separate medication and combination of medicationsare understood by the primary operator in the catheteriza-tion laboratory

Specific premedication, sedation and analgesia for cardiac catheterization

All of the premedications, sedative and anesthetics tioned in the text of this chapter are listed in a detailed

men-“Formulary of Specific Medications used in, or in junction with, the Cardiac Catheterization Laboratory”which is included at the end of this chapter The details ofthe indications, doses by various routes of administrationand for different indications as well as the adverse effectsrelating to the catheterization laboratory environment areincluded in the listing (or table) and are not duplicated inthe general discussion

Con-For newborns and small sick infants, often minimal, oroccasionally even no, premedication is necessary beforebeginning the procedure After administration of the localanesthesia is completed, the catheterization procedureitself is not painful When the infant has adequate localanesthesia, an environmental temperature which is warmand comfortable for the patient, a normal blood sugar,adequate ventilation and the infant is “comfortably”restrained, the very young infant often remains quiet during the procedure with minimal, or even without any,systemic sedation

“Sugar nipples”

Many young infants in the past underwent cardiaccatheterization with the use of a “sugar nipple” as the onlysupplemental sedative/analgesia The “sugar nipple” is astandard rubber or latex nipple off a baby bottle, which isstuffed with cotton and then soaked with a mixture of glu-cose solution and brandy The infant’s emotional suckingneeds, the sugar needs and, presumably, some sedation,are all supplied by the nipple/glucose/brandy combina-tion The cotton is re-saturated with the solution asneeded, although usually the infant sucks on the nippleonly very intermittently and re-saturation of the cotton isnot necessary very frequently, if at all The sedation iseffective and there are never any over-doses or toxicissues The brandy, of course, creates “controlled sub-stance” and “moral” issues, but there still are occasional

institutions which are progressive enough to utilize this

very safe and simple sedation for infants in the cardiac

catheterization laboratory

There are many other more conventional medications

or combinations of medications used as premedication

in catheterization laboratories Most of the individual

medications and combinations are useful for infants, older

children and adults Some of the more common

premedi-cation combinations and sedation/analgesia used in the

catheterization laboratory are covered in the following

paragraphs

“DPT Cocktail”

The “DPT cocktail” combination of meperidine (Demerol),

promethazine (Phenergan), and chlorpromazine (Thorazine)

has been used in a ratio of 2:1:1 mg per kilogram (up to

50 kg) as a premedication for cardiac catheterization for

three and a half decades and is still a useful

premedica-tion/sedative for cardiac catheterization The

effective-ness of the combination relies upon the cumulative effects

of the three drugs with each other, allowing lower doses

and, in turn, fewer side effects of each individual drug

The DPT combination is popular because of its

effective-ness in providing sedation, analgesia and “tranquility”,

which puts the patient to sleep from the sedative and

anxiolytic effects without significantly depressing their

respiration by the opioid

Thorazine does have a very strong alpha blocking effect

with resultant systemic vasodilation, which can result in

systemic hypotension Because of this vasodilation and

hypotension effect, the Thorazine is contraindicated in the

premedication combination in any patient with “tetralogy”

physiology, Eisenmenger physiology or any type of

signi-ficant left ventricular outflow tract stenosis

D & P (Demerol & Phenergan)

In patients in whom Thorazine cannot be used because of

the dependence of the pulmonary or coronary circulation

on the maintenance of the systemic resistance, Demerol

and Phenergan together, but without Thorazine, are used as

the premedication/sedation to start the procedure The

Phenergan provides some sedation and allows a lower

dose of Demerol for effective analgesia However, the two

together without Thorazine are not as effective as DPT,

and must be used in larger doses to provide equally

effect-ive premedication/sedation

Morphine

Morphine is a powerful opiate analgesic with an

anxio-lytic as well as a mild sedative effect The anxioanxio-lytic effect

makes up somewhat for the minimal sedative effect It

pro-vides good premedication in infants and children but alone,

it does not provide sufficient sedation for a procedure unless

it is given in very high, “anesthetic” doses Morphine is a

powerful respiratory depressant in the higher doses and

in high doses provides general anesthesia Usually a zodiazepine or a short-acting barbiturate is used in con-junction with the morphine to provide sedation withoutthe need for a higher dose of morphine Narcan provides

ben-an effective ben-antagonism to the action of the morphine

Fentanyl

Fentanyl is a potent opiate analgesic, with a fast onset ofaction and minimal respiratory depression It has becomevery popular as a premedication for catheterization, alone

or in conjunction with phenergan or thorazine In infantsfentanyl is frequently supplemented with the benzodi-azepine midazolam Fentanyl has the same side effects asmorphine but, in general, to a lesser degree Fentanyl, likethe other opiates, is counteracted with narcan

Midazolam (Versed)

Midazolam is a benzodiazepine which can be givenorally, intramuscularly, intravenously or intranasally.Administered by any of these routes, midazolam provides

a very effective sedative prior to a procedure The oral ornasal routes are more “comfortable” for the patient but theeffects are less predictable by these routes Midazolamalso is a good parenteral supplement to other premed-ications including Fentanyl, the Demerol/Phenergan/Thorazine “cocktail” (DPT) or Demerol/Phenergan (DP)

in older patients

Ketamine

Ketamine is a very effective sedative, with a very rapidonset and short duration of action It can be used either

intravenously or intramuscularly Ketamine is not strictly

an anesthetic or analgesic, but it “dissociates” the patientfrom pain It has a very rapid action, very little respiratorydepression and, if anything, enhancement of blood pres-sure which makes it an ideal “sedative” prior to a catheter-

ization procedureaincluding even the insertion of an

intravenous line Ketamine can be used in small infants

as well as older patients up to late adolescence

Morphine and midazolam or fentanyl and midazolam

In order to avoid respiratory or blood pressure depressionand provide more sedation, morphine or fentanyl is used

in conjunction with midazolam but with a lower dose

of the opiate as well as the midazolam Half of the usualdoses of morphine or fentanyl and then half the usualdose of midazolam are infused sequentially intra-venously The combinations provide excellent sedation/analgesia for cardiac catheterization

Diazepam (valium)

Diazepam is an effective sedative, anxiolytic and amnesicwith a moderate duration of activity It can be given

orally, intramuscularly or intravenously It is a moderate

respiratory depressant and also produces pulmonary

arteriolar vasoconstriction, particularly when delivered

directly into the pulmonary arteries It should not be used

in patients with even the suggestion of pulmonary

vascu-lar disease or pulmonary vasoreactivity Midazolam has

replaced diazepam in most cases as a premedication or

supplemental sedative in the catheterization laboratory

There are many other medications and combinations of

medications that are utilized throughout the world for

premedication/sedation for cardiac catheterization For

the most part, these contain the minimum of a sedative

and an analgesic The particular medicine which is used is

not as important as is the necessity that the responsible

physician is very familiar with each and every medication

which is used in any particular circumstance, in or in

con-junction with, the catheterization laboratory

Supplemental sedatives/analgesics during

the catheterization

Most of the supplemental medications utilized during the

catheterization are the same medications given for

pre-medication, but usually with some variations in the dose

The specific supplemental medications which are used

during the catheterization procedure vary depending on

the needs of each individual patient Some patients

require very little supplemental sedation while others

inexplicably require even double the usual amount or

more frequent administration of the supplemental

med-ications There also are variations in the medications used

in different institutions and even between individual

operators within the same institution

When patients still remain restless or apprehensive at

the onset of the procedure even after they have received

the appropriate premedication and the local xylocaine

has had time to take effect, other possible causes of the

patient’s irritability should always be investigated before

adding supplemental systemic sedation/analgesia The

operator is responsible for investigating all other possible

causes of the patient’s discomfort/irritability There are

some particularly suspect areas as the causes of patient

discomfort and restlessness

The most common area of discomfort is the area of the

needle puncture or the sheath/dilator introduction The

operator must be sure that the skin area being

manipu-lated is not “outside of the area” of the local anesthesia

Additional local anesthesia in both the cutaneous and

sub-cutaneous tissues is often more effective than even a

sup-plemental full dose of the patient’s premedication

After inadequate local anesthesia has been eliminated

as the source of discomfort and restlessness, there still are

other causes of discomfort to be ruled out before any

addi-tional systemic sedative/analgesia should be added The

tape or restraints securing the patient on the table can betoo tight, can bind the patient’s extremities tightly or fixthe extremities in an uncomfortable position The environ-

mental temperature in the room should be comfortable for the patientathis is particularly important with the small,

thin or debilitated patient The patient’s bladder shouldhave been emptied before the patient was premedicatedand must have adequate drainage during the procedure.The discomfort of a full bladder cannot be overcome with sedation or analgesia The blood sugar of all infantsshould be checked, particularly after any duration ofbeing “nothing by mouth” or when an intravenous line isnot in place with supplemental glucose running Finally, it

is essential that the patient’s hemodynamic parametersare stable before the administration of additional sedation

is considered It is mandatory to have the arterial ing line in place before supplemental sedatives are given

monitor-In addition to providing a continual and accurate display

of blood pressure, the arterial line provides access forobtaining arterial blood oxygen saturations and bloodgases at any time throughout the procedure

Additional supplemental sedatives or analgesics should

be administered during the procedure in response to thepatient’s needs Just as with restlessness at the onset of thecatheterization, when a patient and particularly an infant

on the catheterization table becomes restless or begins

cry-ing durcry-ing the procedure, the patient again is investigated

critically for a source of discomfort as just described.Again, the first supplemental medication to be considered

is usually additional local anesthesia at the site of the

catheter introduction If there is adequate local anesthesia

at the introductory site, the catheter manipulations withinthe vascular system and heart do not cause pain Once alltreatable sources of the patient’s restlessness are excluded,only then is the patient re-sedated

Supplemental sedation is also added arbitrarily and

periodically during very long cases to preempt the patient’s

waking and becoming anxious and uncooperative plemental sedation is given prophylactically just before

Sup-particularly delicate or critical procedures are performeda

for example, extra sedation is given just before the precisepositioning of intracardiac devices (atrial septal defect(ASD) occluder devices, stents) Extra analgesia is givenjust before an interventional procedure that is expected toproduce pain (particularly large vessel dilations)

Following the administration of even small doses ofsedative, patients, particularly infants, are observed andmonitored very carefully for signs of respiratory depres-sion In the event of transient respiratory depression,

any type of physical stimulationaeven minimalaof the

patient or a few breaths with an Ambu™ face-mask isoften enough to reverse it In the event of prolonged respir-atory depression, intubation and controlled ventilationmay be necessary